


/ 









-^ 



,\ -/ / 






* 


















»0o. 
















I 



* v '^ 



^ % 












■=,'-*-. 



V V* 
















' -. 



A* * 






-/ V- 












1 
1 





















- 


















































































\~ 









A 

PRACTICAL TREATISE 

ON TUL 

MANAGEMENT AND DISEASES 

01 

CHILDREN. 



' 



RICHARD T. E\ ANSON. M.D., 

fr.UFK.JiOR OF Mt 1 HI IEELARD 



HENRI MAUNSELL, .M.D., 

'R Of POLITICAL KSMCUI 1> lilt EOTAl 



\Ml i:i« IB i i.i\ I D1TI0M 

OT(tt) > 

B1 I), ra kNCIS < ONDIE, M.D.. 

FRLLUW OF 1 UM if PHILADELPHIA, MkMBHR 01 TUB AMERICAN 

PHILOSOPHICAL BOilRTr, ETC. 






iJhiiatjrlpiiia : 
ED. BARRINGTO^ & GEO. 1). HA8WELL 

18 4 3. 



> dF 

y <\>* 



fb 



[Entered, according to act of Congress, in the year 1843, by Babrington and 
Haswkll, in the Clerk's office of the District Court for the Eastern District of Penn- 
sylvania.] 



/ * -> 






PREFACE 

BY THE AMERICAN EDITOR. 



In presenting a Second American Edition of the Treatise of Drs. 
Evanson and Maunsell, it may not be improper to state that we 
consider the work, as revised and enlarged by the authors in their 
Fourth Edition, to constitute one of the best manuals we possess of the 
diseases of children, and one especially adapted for the use of the 
student and young practitioner. It embraces a very full account of 
the principal affections peculiar to the early period of existence — 
the phenomena of which are described with great accuracy, while the 
views advanced in relation to their pathological character, as well as 
the directions given for their therapeutical management, are evidently 
the result of extensive personal observations, and a careful study of 
the views and experience of the best modern authorities. 

In preparing the present edition for the press, it was not considered 
expedient to enlarge the size of the work by the addition of a large 
number of notes : nor was this necessary, — the authors' opinions 
and practical directions corresponding very generally with the re- 
sult of our own observations and experience. In two instances, 
however, we have been induced to extend our notes to some length. 
Thus, the brief notice presented by Dr. Evanson, in the Chapter on 
the Diseases of the Digestive Organs, of the Gangrene of the Mouth in 
Children, being extremely incomplete, and withal somewhat con- 
fused, we have appended an account of the symptoms, etiology, and 
treatment of this important malady, derived from our own observa- 
tions, and those of the principal European writers who treat espe- 
cially of the disease. A similar course has been pursued in relation to 
the account of Cholera Infantum, contained in the same chapter ; a 



I PKEFACE. 

disease of which Dr. Evanson has evidently seen but little, and which 
lie has strangely confounded with another and very different disease 
of the digestive organs. 

No changes have been made in any portion of the authors' text 
or notes — the whole being carefully printed from the last Dublin 
edition, with the exception of a long addendum to the seventeenth 
section of the sixth chapter, containing a reply to some criticisms upon 
Dr. Maunsell's account of infantile jaundice, that appeared in the 
British and Foreign Medical Review, which is omitted as altogether 
uninteresting to the American reader, and adding nothing either to 
the interest or value of the work. 



ADVERTISEMENT 

TO THE FOURTH EDITION 



The Publishers have to apologise for this Edition having been, 
owing to unavoidable circumstances, delayed somewhat beyond the 
period for which its appearance was at first announced. They have 
much pleasure, however, in stating that the time has been employed 
in a careful revision of the whole work, which is now greatly 
enlarged and, they trust, considerably improved. A new chapter 
has been added, in which those diseases of the skin, not treated of in 
former Editions, are practically considered ; thus completing the 
work, and, it is hoped, rendering it more worthy of a continuance of 
that public favour which has already been, so abundantly, bestowed 
upon it. 

On the part of the Publishers every exertion has been made in 
order to bring out the present volume in a creditable manner. The 
work was originally undertaken at their suggestion, and they have 
now gratefully to acknowledge the public proof of the correctness of 
their opinion, as to the demand for such a publication, which has been 
afforded by the rapid sale of three large Editions, by the republica- 
tion of the « Treatise' in America, and by its translation into the Ger- 
man language. 

41, Grafton-st., April, 1842. 



PREFACE TO FIRST EDITION. 

A preface usually embraces two topics, viz. : — the Author's 
reasons for publishing ; and such an account as he chooses to give 
of his qualifications for the task he has undertaken. 

With regard to the first, we have only to state, that our Publisher 
informed us that a concise practical work upon the Management and 



f, PREFACE. 

Diseases of Children was a desideratum in British medical literature. 
Respecting the second, all that becomes us to say is, that we have 
been connected with the Institution for Diseases of Children ever 
since its establishment in this city : first, as students ; and subse- 
quently, as medical attendants. We had thus, at least, ample oppor- 
tunity of attaining experience in the subject. If it should now prove 
that we have profited by this so far as to enable us to render the fol- 
lowing Chapters (incomplete as we know them to be), in any degree 
useful to society, we shall be more than recompensed for the labour 
they have cost us. 

Dublin, Nov. 1S36. 



PREFACE TO SECOND EDITION. 

The First Edition of this Treatise having met with a favourable 
reception from the Profession, and a rapid sale, we might, perhaps, 
be excused for inferring that it has, in some degree, supplied the 
want of a " concise practical work upon the Management and Dis- 
eases of Children/' which our publisher informed us had been u a 
desideratum in British medical literature." If such an inference 
were admitted to be correct, little would now require to be said in 
the way of preface, but as we are ourselves still conscious of many 
imperfections and omissions, it may be well to state briefly our own 
view of the scope and character of the work which, as it appears to 
us, have been in some measure misunderstood. 

Our desire, from the commencement, was to produce a systematic 
Treatise upon the subject in hand, which, while strictly based upon 
the knowledge we had ourselves, personally, acquired during many 
years of painful and laborious observation of infantile disease should, 
at the same time, present a correct view of the most recent improve- 
ments, both pathological and practical, in this department of medical 
science. In attempting to accomplish this latter portion of our ob- 
ject we have taken advantage of the researches of our Continental 
brethren, whose industry has, in many instances, been beneficially 
directed towards the valuable opportunities afforded them in their 
numerous and extensive institutions, devoted exclusively to the study 
of the diseases of childhood. From their works we have been en- 
abled to enrich our pages with information not generally known 
among British practitioners, and have, therefore, found frequent oc- 
casion (in our wish to attribute honour to whom honour is due), to 
quote the opinions and names of Foreign writers. In doing so, how- 
ever, we have not forgotten to study and refer to works of British 
origin, which, though not very numerous or recent, yet exhibit much 
accurate acquaintance with infantile disease, and usually inculcate a 
sound practice. Whether quoting from British or Foreign sources, 
we have been always desirous to give to each due credit for every 



PREFACE. 7 

original observation, but where opinions have become the staple and 
common property of science we have not thought it necessary to 
encumber our pages by special references to their originators, or re- 
vivers, believing that the names of the first should be known to all 
our readers, and that those of the second are entitled but to a para- 
sitic reputation. 

In addition, we must say, that though thus willing to make our 
work as complete as possible by collecting information from all quar- 
ters, we have not adopted the opinions of any authors merely on 
their own dicta, nor put forward any rules of practice upon the au- 
thority of others, to which we did not feel justified in giving assent 
by the results of our own practical experience. It was our primary 
object to make the Treatise on the Management and Diseases of 
Children a practical work, and it is upon our own experience that 
the information which it contains is founded, although we have 
shunned, as not fashioned to our taste, the egotistical style of trumpet- 
ing forth every particular observation as a new discovery. In *a word, 
we consider our book so far original that we are not aware of any 
other, constructed in the same manner, or treating in the same way 
of all the topics which we have introduced, several of them not having 
been even touched upon in other systematic works upon the subject : 
still, as we have already stated, we are well aware that much re- 
mains to be done, and not a little to be amended. 

Few authors have less reason or inclination than we to complain 
of the measure of criticism which has been dealt out to us ; even where 
fault has been found it has been often done with sound judgment, 
and generally in a good spirit. Our appreciation of this cannot be 
better shown than in the willingness with which we have, in the 
present edition, availed ourselves of judicious criticism in the amend- 
ments and additions which we have thought it advisable to make. 

To please all, however, and adopt every alteration suggested, would 
be a difficult and hopeless task ; in attempting which we should, 
indeed, find it necessary at the same time to enlarge and to curtail 
the same Chapter ; or in order to please one, altogether to omit that 
which another assures us constitutes one of the most valuable parts 
of the work ; while the ignorance of the subject betrayed by some, 
who have given their judgments with the utmost complacency, has 
proved to us absolutely amusing. 

Meaning, then, to eschew the example of that amiable old gentle- 
man who endeavoured to conduct his donkey to market, so as to 
please every one, we propose, with due submission to Messrs. the 
Reviewers — from whom we part in all good humour and with some 
sense of obligation — to ride our own hobby even in the way that 
likes us best. 

Dublin, March, 1838. 



PREFACE. 



PREFACE TO THIRD EDITION. 



In presenting the present Edition of this Treatise to the profes- 
sional public, we have little to say, beyond the expression of our 
wannest thanks for the kind and flattering reception met with by 
its predecessors. In preparing these sheets for the press, it has been 
our constant desire to acknowledge our numerous and heavy obliga- 
tions in, what appeared to us, the most suitable manner, viz., by an 
anxious endeavour to render the Work more deserving of the 
patronage which has been hitherto afforded it. 

Dublin, August, 1840. 



CONTENTS. 



CHAPTER I. 

PECULIARITIES OF THE INFANT STRUCTURE AND CONSTI- 
TUTION. 



Sect. 1. General Considerations 

2. Digestive Organs 

3. Organs of Respiration 

4. of Circulation 

5. Cerebro-spinal System 

6. Locomotive Apparatus 

7. Growth 



PAGE 

13 
15 
17 
18 
20 
22 
23 



R. T. Evanson. 



CHAPTER II. 
MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. 

Sect. 1. Management immediately after Birth — Washing and Dressing 



2. Food and medicine, do. 

3. in the First Period 

4. Choice of a Nurse 

5. Artificial Feeding 

6. Weaning 

7. Food in Second Period 

8. Cleanliness 

9. Clothing 

10. Sleep 

11. Exercise 

12. Medicine 

13. Light 

14. Air 

15. Heat 



do. 



H. Maunsell. 



CHAPTER III. 
MENTAL AND MORAL EDUCATION. 



31 
35 
36 
39 
40 
41 
41 
45 
47 
49 
52 
54 
56 
57 
57 



Sect. 1. Mental Education 
2. Moral do. 



H. Maunsell. 



58 
62 



l0 CONTENTS. 

CHAPTER IV. 
PECULIARITIES OF DISEASE. 

PAGE 

Sect. 1. Etiology 66 

2. Diagnosis ... ... ... •«• ••• ?. 

3. Prognosis 



81 



R. T. Evanson. 



CHAPTER V. 
INFANTILE THERAPEUTICS. 



1 ... 


... 


83 


. ... 


... 


88 


. 


... 


91 


• •• 


••• 


94 


• •. 


••• 


95 


• ••• 


... 


97 


• ... 


... 


98 


• .. • 


... 


103 


• ... 


,., 


103 


• ... 


... 


107 


1 ••• 


... 


110 


. 


... 


113 


. ... 


... 


116 


, „, 


... 


117 


, ,„ 


... 


119 


1 ... 


,,, 


122 


R. T. Evanson. 







Sect. 1. General Observations 

2. Mercury • 

3. Sedatives 

4. Alkalies and Alkaline Earths 

5. Carminatives 

6. Stimulants 

7. Tonics ... 

8. Antiphlogistic Plan 

9. Bloodletting 

10. Blisters ... 

11. Emetics 

12. Expectorants 

13. Diaphoretics 

14. Refrigerants 

15. Baths ... 

16. Purgatives 



CHAPTER VI. 

ACCIDENTS AND DISEASES OCCURRING AT BIRTH, OR SHORTLY 

AFTERWARDS. 

Sect. 1. Still-born Children ... 
2. Imperforate Anus 

3. Vagina ... 

4. Penis 

5. Spina Bifida ... ... .., 

6. Short Frenum Linguae 

7. Hare-Lip ... 

8. Deformed Feet 

9. Naevi Materni 

10. Ruptures ... 

11. Injuries received during Birth 

12. Blue Disease 

13. Trismus Nascentium 

14. Infantile Erysipelas ... 

15. Abscesses ... 

16. Induration of Cellular Tissue 

17. Jaundice 

18. Purulent. Ophthalmia 

19. Red Gum ... 

20. Swelling of the Breasts 



... 


. 132 


... .. 


. 135 


... .. 


. 136 


... •• 


; 136 


... 


. 137 


... .'1 


, 139 


... .. 


. 139 


... .. 


140 


... ••< 


141 


... ••' 


, 143 


... ..< 


146 


... 


147 




147 


... 


149 


..• 


151 


... 


151 


... ,,, 


153 


... 


153 


... 


157 


,,. 


158 


. Maunsell. 





CONTENTS. 11 



CHAPTER VII. 

AGS 

DENTITION ... 158 

R. T. Ev ANSON. 



CHAPTER VIII. 

DISEASES OF DIGESTIVE ORGANS. 

Sect. 1. General observations ... ... ... ... ... 167 

2. Affections of Mouth, Pharynx, &c. ... ... ... 169 

a. Inflammation ... ... ... ... ... 169 

b. Ulceration ... ... ... ... ... 169 

c. Aphthae ... ... ... ... ... 170 

d. Muguet ... ... ... ... ... 173 

e. Diphtherite ... ... ... ... ... 174 

f. Gangrene ... ... ... ... ... 179 

g. CancrumOris ... ... ... ... ... 181 

Gangrene of the Mouth [D. F. Condie] ... ... 182 

h. Mumps ... ... ... ... ... 189 

3. Affections of Stomach and Bowels ... ... ... 190 

a. Indigestion ... ... ... ... ... 192 

b. Cholera ... ... ... 198 

c. Diarrhoea ... ... ... ... ... 207 

d. Inflammations ... ... ... ... ... 218 

4. Mesenteric disease ... ... ... ... ... 228 

5. Worms ... ... ... ... ... ... 236 

6. Remittent Fever ... ... ... ... ... 242 

R. T. Evanson. 



CHAPTER IX. 
DISEASES OF THE RESPIRATORY ORGANS. 



Sect. 


1. Catarrh 




2. Bronchitis 




3. Pneumonia 




4. Pleuritis — Pericarditis 




5. Croup 




6. Laryngitis 




7. Foreign Bodies in Larynx 




8. Spasm of the Glottis 




9. Hooping Cough 



... 


... 


250 


... 


... 


251 


... 


... 


254 


... 


... 


255 


... 


... 


255 


... 


... 


261 


... 


... 


263 


... 


... 


265 


... 


... 


268 


H. Maunsell. 







CHAPTER X. 

DISEASES OF THE CEREBRAL SYSTEM. 

Sect. 1. Functional Diseases ... ... ... ... ... 274 

2. Inflammatory Affections ... ... ... ... ... 280 

R. T. Evanson. 



j CONTENTS. 

CHAPTER XL 
ERUPTIVE FEVERS. 

TAGE 

Sect. 1. Measles ... ... ... ... ... ... 292 

2. Scarlet Fever ... ... ... ... ... ... 298 

3. Small-pox ... ... ... ... ... ... 308 

4. Chicken-pox ... ... ... ... ... ... 315 

H. Maunsell. 

CHAPTER XII. 

VACCINATION ... 316 

H. Maunsell. 

CHAPTER XIII. 
CONSTITUTIONAL DISEASES. 

Sect. 1. Scrofula ... ... ... ... ... ... ... 338 

2. Rickets ... ... ... ... ... ... ... 348 

3. Syphilis ... .. ... ... ... ... ... 350 

4. Purpura ... ... ... ... ... ... ... 354 

5. Pemphigus ... ... ... ... ... ... 356 

H. Maunsell. 

CHAPTER XIV. 
DISEASES OF THE SKIN. 

Sect. 1. Erythema (Scalding) ... ... ... ... ... 359 

2. Urticaria (Nettle Rash) ... ... ... ... ... 360 

3. Scabies (Itch) ... ... ... ... ... ... sqo 

4. Crusta Lactea ... ... ... ... ... ... 36i 

5. Herpes (Ringworm) ... ... ... ... ... 362 

6. Tinea Capitis (Scald Head) ... ... ... ... 363 

H. Maunsell. 






PRACTICAL TREATISE 

ETC., ETC. 



CHAPTER I. 

PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. 
I. GENERAL CONSIDERATIONS. 

In considering the peculiarities of the infant structure and consti- 
tution, as well as in the observations which we propose to make 
upon the diseases of children, we shall regard the period of childhood 
as consisting of two epochs — the first commencing at birth, and 
continuing until the twelfth month ; the second commencing at the 
termination of the first year, and continuing until the eighth. 

This division, which has been generally adopted, possesses the merit 
of being nearly in accordance with one definitely marked out by nature 
herself. About the tenth or twelfth month, the child, by its acqui- 
sition of teeth, becomes fitted for the use of other nourishment than 
the mother's milk; and the stomach and bowels receive, not merely 
with impunity, but with advantage, kinds of food, which, during the 
earlier months, would have been productive of serious derangements 
of the digestive functions ; at the same time, very obvious external 
changes have their commencement, and indicate marked alterations, 
both bodily and mental.* During the first period, also, the child is 
subject to some peculiar diseases and dangers, to which the attention 
of the physician requires to be specially directed, and the diminished 
liability to which, upon the commencement of the second epoch, 
together with an increasing power of resisting disease, adds materially 
to the chances of existence. 

Beyond the eighth year, we would not employ the term, child — 
though applied by some until the age of puberty : but before then, 
the peculiarities characteristic of childhood have been merging into 
the attributes of adult age ; while the influence of sex begins to be 

* " At this time," says Wendt, " the hitherto projecting forehead becomes 
flattened, the countenance receives expression, the eyes intelligence, the limbs firm- 
ness." — Die Kinderkrankheiten syslematisch dargestellt von Dr. J. Wendt. Wien, 
1827. 

2 



14 PECULIARITIES OF INFANTS. 

discernible, and the individual may thenceforward be designated boy 
or girl. 

The infant, at birth, is endowed with the same organs as the 
adult ; but so different, for the most part 3 in structure, development, 
or even situation, as to constitute essential characters, which distin- 
guish childhood, and without a knowledge of which, neither the 
management nor diseases of children can be correctly understood. 

Infancy may be emphatically termed the period of growth. We 
find the infant, at birth, fully provided with the organs of nutritive or 
organic life — those which are essential for the sustenance and nutri- 
tion of the individual ; while the organs of animal life or relation, — 
those which connect man with the external world, and make him, 
on their completion, the superior being that he is, — are as yet but 
imperfect in development or structure, and herein is to be found the 
basis of that great difference observable between the infant and the 
adult. In the former, we have the organs of nutritive life alone, 
fully developed, and actively employed ; but in the latter, we have 
both classes of organs, relative as well as nutritive, brought to com- 
pletion and in full activity, constituting the period of maturity or per- 
fect growth. 

To speak in general terms, we may say, that the anatomical struc- 
tures in the infant differ from those in the adult, by their greater 
softness or want of consistency ; being surcharged with fluids, and 
many of them as yet unfitted for the full discharge of their appropriate 
functions ; while in advanced life, on the contrary, the quantity of 
fluids diminishes, and the structures become condensed, so that the 
organs, instead of being too soft, have become too rigid, as we find 
them to be in old age. In the infant, the glandular and capillary 
systems predominate ; absorption and deposition are active, and the 
processes of interstitial growth most vigorous ; secretion is abundant, 
and excretion frequent; the nervous sensibility being acute, and the 
membranes remarkable for their vascularity ; all which phenomena 
depend, not merely on the abundance of blood present, and the 
activity of its circulation, but on the preponderance of the arterial 
over the venous vessels. 

Before proceeding to a particular review of the several organs, and 
the properties by which they are characterized in childhood, it may 
be well to take a glance at the general appearance of the newly-born 
infant. 

The length of the body varies from about one foot and a half to a 
little less than two feet. Baudelocque states sixteen inches and 
twenty-two (or at most twenty-three) inches, as the extreme limits. 
The average weight is from about six to seven pounds and a half ; 
more has been assigned, but is not common ; six pounds is by far 
the most common weight, according to Camus's Tables. 

The skin is thin, tender, and of a reddish hue ; but covered at 
birth with a white unctuous matter, called vemix caseosa. There is 
some hair upon the scalp, and the nails reach to the ends of the 
fingers : the articulations are commonly flexed, the limbs round, and 
the body plump. 



DIGESTIVE ORGANS. 15 

The relative dimensions of various parts differ materially from those 
observed in after life. The lower extremities are less developed 
than the upper ; the median point, — that lying midway between the 
two extremes of the body — being found at the umbilicus, or a line 
or two below it. The pelvis in the infant is small and contracted, 
being less developed in proportion than the thorax, which is flattened 
at the sides, but prominent in front ; while the abdomen and head 
present dimensions, not only very large in comparison with the 
other cavities, but also as compared with their own dimensions in 
after life. 

The newly-born infant possesses little power of motion ; none of 
independent support. Sensation and perception are dull or absent. 
Its cries and movements may be looked on as involuntary — its search 
for food is instinctive. One-third of its time is chiefly occupied in 
taking nourishment, the remainder is passed in sleep. 

Peculiarities not less striking or important, arrest our attention, on 
turning to the consideration of the internal organs ; and these we 
shall briefly notice in succession, commencing with those of organic 
life, as being first called into action ; and of these the digestive organs 
naturally claim precedence, and will be found in a high state of 
development. 

II. DIGESTIVE ORGANS. 

The mouth of the infant is fully formed, and in some respects par- 
ticularly adapted to the performance of its proper office of suction, 
as we see in the disposition of the palate and lips and the obliquity 
of the posterior nares ; yet appearing to be imperfect from the want 
of teeth, which, however, can hardly be said to be wanting — only 
absent ; as they already exist within the gum, in due time to make 
their appearance and mark a new era, when the child becomes fitted 
for a different aliment, from that hitherto provided by nature for its 
sustenance. 

The mucous membrane lining the fauces, pharynx, stomach, and 
the whole tract of the intestinal tube, is thick and villous ; being 
more sensitive and vascular than in after periods of life ; softer in tex- 
ture, and more bedewed with mucus, which is abundant, but thin ; 
becoming viscid, however, and much increased in quantity on the 
occurrence of any irritation. The sensibility of the mucous mem- 
brane is adapted to the mild unirritating fluid provided by nature as 
the suitable nourishment for the infant : any other substance proves 
irritating in a greater or less degree, and is therefore to be avoided. 

The stomach and duodenum are fully formed, their mucous mem- 
brane being thick, villous, and of a rosy tint. But the position of 
the stomach in the infant, differs from that in the adult, in hanging 
almost perpendicularly, so as to extend from the epigastric to the 
umbilical region : instead of being placed in the transverse position 
which it occupies in after life. The omentum, which is attached 
always to the great curvature of the stomach will, in consequence, 
be found in the infant, more towards the left than the right side. 
The small intestines in the infant are a third longer in proportion to 



16 



PECULIARITIES OF INFANTS. 



the Length of the whole intestinal tract, than in the adult; and the 
large intestines are longer in proportion to the small, but their calibre 
is relatively less. The valvulae conniventes are scarcely apparent ; 
the vermiform process is very long, and the coecum is largely de- 
veloped. 

The salivary glands and the pancreas are very large, and seem 
particularly active ; the whole glandular system being much larger, 
in proportion, in the child, and more active, so as to give to the infan- 
tile constitution a peculiar and important character. 

Digestion is rapid and incessant ; the child frequently requiring 
food^which, if permitted, will be often taken to repletion ; so as to 
be ejected without effort from the overloaded stomach, which is 
not capable of containing more than a few ounces of fluid at a 
time. 

The chyle, which is rapidly eliminated, is quickly absorbed, the 
tract of the small intestines being long, as we have seen ; while the 
lacteal vessels and mesenteric glands are largely developed, and in a 
high state of activity. 

The gall-bladder, though small at birth, soon enlarges ; and is 
found to contain bile, bitter in taste, and green in colour : but bile, 
in the infant, is less viscid and less charged with the principles pecu- 
liar to this fluid, than at a more advanced age, when concretions are 
liable to form. 

The liver undergoes a remarkable alteration in function and form 
after birth. The mode of circulation is changed ; the left lobe dimin- 
ishes, the umbilical vein and canalis venosus are obliterated ; while 
the vena portae is developed, and the secretion of bile becomes the 
peculiar function. The parenchyma of the liver becomes darker as 
life advances ; and the size of the organ diminishes relatively in 
volume, receding towards the ribs, within which it is situated in the 
adult ; but in the infant, it extends to the middle region of the abdo- 
men ; and instances are recorded, where the proportions of the liver 
remained through life as in the foetus. 

The spleen presents little peculiarity that we are as yet able to 
notice ; too little is known of its functions to enable us to appreciate 
any changes that may occur ; but we have observed, that it is sub- 
ject to disease at a very early period. The spleen may be felt in the 
infant below the false ribs, chiefly in the middle region; not in the 
left hypochondrium, as in the adult, in whom indeed the spleen 
can hardly be discovered by the touch unless when in a diseased 
state. 

The bowels, at birth, are found to contain a dark-coloured inodo- 
rous, insipid substance, which is called meconium, and appears to 
result from accumulation of intestinal secretion, for which passage 
had not before been provided. This is, however, soon expelled, and 
its place occupied by the residue of the food ; which, from the nature 
of the infant's aliment, we might conjecture, would be but little cha- 
racterised by the properties of fecal matter. — Accordingly, we find 
the contents of the bowels in infants, much less feculent than they 
afterwards become ; being thin, charged with mucus, and of a yel- 



ORGANS OF RESPIRATION. 17 

lowish colour ; possessing little fetor, but abundant and frequently- 
expelled, the infant passing a stool three or four times each day. 

In a similar manner, we find the other excretions less odorous, 
more watery, and not so largely charged with their peculiar prin- 
ciples, saline or otherwise, as in the adult; but they are quickly 
discharged, though not very abundantly secreted. The perspiration 
is less saline and odorous, but more watery, though not copious. 
The urine differs in like manner from that of the adult (in particular, 
the quantity of urea is much less) ; and it is retained a much shorter 
time, being, like the feces, often expelled. This does not depend 
merely on the constant supply of food, or less relative capacity of the 
containing viscus ; but is connected with the peculiar sensibility of 
the lining membranes, and irritability of the muscular coats of these 
viscera ; which, like the other involuntary muscles, are more irrita- 
ble in the infant, than they are subsequently found to be. In their 
tissue, they are softer and of a paler hue ; nor has command over 
their actions been yet acquired. 

This latter character, in particular, attaches to the urinary bladder 
in the child, and occasionally continues to give annoyance for some 
time, by leading to frequent wetting of the dress or bed-clothes. 
The bladder, in the infant, is more elongated in shape, and situated 
higher up, than that of the adult ; but is less capacious in proportion, 
while the ureters are particularly large. But it is upon its difference 
of anatomical structure, as regards the position of the urethra, more 
than perhaps other circumstances, that this difficulty of retaining the 
urine depends ; for the pouch or fundus of the bladder (bas fond) 
does not exist in the fetus, the cervix or urethral opening being 
then most dependent ; and this state of parts still obtains to a cer- 
tain degree in the young subject; probably in some more than 
others. 

The kidneys undergo remarkable alteration ; their lobular for- 
mation disappearing, and the supra-renal capsules rapidly diminish- 
ing; but the relation which these changes bear to the functions of 
the organ, is not very obvious. 

III. ORGANS OF RESPIRATION. 

Having considered the digestive organs, or those which generate 
the materials for the blood, we shall now notice the respiratory organs, 
or those by which the blood is regenerated, and fitted again for the 
purposes of the circulation. 

In no organs do more important changes occur, at birth, than in 
the lungs ; in nothing does the infant more remarkably differ from 
the foetus than in being a respiratory animal. The lungs, which be- 
fore birth had been condensed, of a brownish-red hue, very vascular, 
and not as yet permeated by air, now suddenly augment in size, 
becoming, after respiration, of a rosy colour, soft and vesicular in 
structure, and crepitant to the touch. 

The respiratory process, (which, in the child, is in a great mea- 
sure performed by the action of the ribs alone,) is carried on with 
2* 



IS PECULIARITIES OF INFANTS. 

rapidity and force, consonant to the general activity observable 
throughout the system ; and in particular, the constant demand for 
fresh supplies of blood. The inspirations and expirations are equal 
and frequent ; the more frequent, the younger the child ; being, 
during the first year, from 35 to 40 in the minute, or nearly double 
those of the healthy man ; while the sound emitted on the passage of 
the air, is so peculiar from its force and sonorousness, as to obtain 
the distinguishing appellation of puerile respiration. This charac- 
ter, respiration in the adult occasionally assumes, when the healthy 
portion of a lung is obliged to take on a compensatory action, in 
consequence of obstruction in the diseased portion (as in Pneumonia) 
— when the respiration in the sound part is said to be puerile, as 
significant of its force. 

Notwithstanding this activity in the process of respiration, it would 
appear that less oxygen is consumed in the infant than the adult, 
and that the power of generating heat (a process closely related to 
respiration) is also less. 

The thymus gland, which occupied a large and conspicuous space 
within the upper and anterior part of the thorax in the foetus, gradu- 
ally diminishes after birth, and is hardly to be recognised in the adult. 
It is freely supplied with veins and arteries, and contains at first a 
whitish fluid somewhat like chyle, which shows the gland to have a 
secreting power ; but it is not generally acknowledged that any ex- 
cretory ducts exist. Its supply of bloodvessels and softness of tex- 
ture, seem to allow of sudden augmentation of size ; and this, in 
instances where the gland is larger than ordinary after birth, may 
cause, by the pressure exerted on subjacent and important parts, very 
distressing or dangerous symptoms. To such cause has been attri- 
buted a spasmodic affection, to which some children are liable, and 
which often proves fatal ; at least, the thymus gland has been found 
distended or enlarged in some such instances. In common, it does 
not exceed a couple of inches in length, one and a half in breadth, 
and a quarter of an inch in thickness. 

IV. ORGANS OP CIRCULATION. 

The blood, having undergone the requisite changes in the lungs, is 
conveyed again to the heart, thence to be sent throughout the system 
From the moment the act of respiration is performed, the circulation 
undergoes a total change ; and the heart is altered accordingly, be- 
coming complete in its functions, but still retaining some remarkable 
peculiarities in the infant. Its volume is proportionably large ; but 
the relative capacity of its cavities differs from what is afterwards 
observed, those of the left side, — particularly the ventricle, and, in 
connection, the arteries — preponderating decidedly at first: the 
balance, however, is gradually altered, until we find, in the adult, the 
cavities of the right side of the heart nearly three times the size of 
those of the left. 

The thickness of the parietes of these cavities, however, changes 
inversely with their capacity ; for,frombeing nearly equal, the parietes 



ORGANS OF CIRCULATION. 19 

of the left ventricle become almost four times as thick as those of 
the right — a change which rapidly proceeds after the obliteration of 
the ductus arteriosus, and the closure of the foramen ovale, when 
the left ventricle has the sole conduct of the circulation through the 
system. 

The parietes of the heart are softer and paler than in after life, 
when the relative bulk is less, but the texture firmer, and colour 
deeper ; this organ being then called upon to propel its contents with 
greater force, as they have to traverse a longer space. In the infant, 
the large volume but feebler power of the heart fits it for the propul- 
sion of a larger quantity of blood, but through a less distance ; while 
the peculiar irritability of this, as well as the other hollow muscles, 
during infantile life, ensures more active contractility, and so, more 
rapid action, suited to the constant demand for fresh supply. Ac- 
cordingly, we often find the pulse in the infant, like the respiration, 
nearly double in frequency that of the adult, varying from 120 to 140 
oeats in a minute.* 

The part of the nervous system more immediately connected with 
the class of organs which we have just been considering, should 
naturally be in a high state of development, to allow of that fulness 
of function which we have seen these organs to possess: and accord- 
ingly, we find the ganglions, or system of the sympathetic nerve, 
very perfectly formed at birth ; while the brain, and its nervous con- 
nections, on the contrary, are very imperfectly formed, though largely 
developed — more especially the brain itself. 

We now come to the consideration of the second class of organs, — 
those of animal life, or relation to external objects ; and here we shall 
find remarkable changes manifested in the advance of organs from a 
state of essential imperfection, to one of completeness — this advance 
in organization, and successive development of function, constituting 
the most interesting eras of infantile life, looked forward to with 



* The pulse in the child varies so much in different individuals, and according 
to different circumstances, that it is very difficult, if not impossible, to assign a rate 
of frequency according to the age. Some general conclusions may, however, be 
come to, and a proximate, if not accurate, guide thence derived in disease ; but the 
most experienced practitioners are most cautious in drawing conclusions from the 
frequency of the pulse in the young child. The influence of position is very re- 
markable — a change from the recumbent to the sitting posture at once adding 
greatly to the frequency of the pulse — much more when the attitude is erect and 
the child in motion. We have often found the pulse, which at night (during sleep) 
was 80, full and steady ; up to 100 or even 120 during the day, small and hurried 
— and that in more grown children (six or seven years of age), and in perfect health. 
While, on the other hand, in very young infants (under six months old), the pulse 
may continue quite unaffected during dangerous illness — particularly serious ab- 
dominal affections. The most general conclusion which our observations have 
enabled us to make, is, that the pulse is not most frequent immediately after birth, 
but at the age, or at least the time of teething ; and that it thence gradually dimi- 
nishes in frequency. This view accords with the experiments of Dr. J. Gorham, 
who assigns 130 as the mean number of the pulse from five months to two years 
old; and 107.G3 from two to four years of age; whence the number continues 
almost the same up to the tenth year. See the Mtdical Gazette for 1837. [Note to 
4th Edition.] 



20 PECULIARITIES OF INFANTS. 

eagerness, and remembered with pleasure, as the periods of dawning 
intelligence, and independent muscular exertion — when the infant 
first begins to take notice, to walk alone, and to speak. 

y. CEREBRO-SPINAL SYSTEM. 

The brain, though large in volume, is very imperfect in structure 
in the infant, being so soft as to be almost fluid, the quantity of 
aqueous matter preponderating much over the albuminous ; it is of a 
reddish hue, but with the cortical portion less deeply coloured than 
in adult age, and the convolutions less deeply marked. 

The brain is altogether inadequate to perform, on first entrance 
into life, those exalted functions which afterwards render it so im- 
portant an organ, and so characteristic of the superiority of man ; and 
accordingly, we find the newly-born child incapable of thought, and 
apparently devoid of perception. 

As the action of the heart becomes more vigorous, the brain ac- 
quires more energy. The precise changes which this organ under- 
goes, in its progress towards perfection of structure, are not accurately 
determined ; but those appear to be as important which regard 
alterations in the quality,* as in the quantity of the cerebral sub- 
stance. The increase in size is not, perhaps, so remarkable as that 
in the density of the organ ; which, according to Wenzel, does 
not attain its greatest weight until the seventh year, — the size 
and weight of the brain at that time being said to differ little from 
what they are at mature age, when the power of function is so far 
superior. 

Such is the opinion generally entertained on this subject ; but which 
is not strictly accordant to fact. The fact is, the brain does con- 
tinue to increase in size until manhood ; and the relative size of its 
different parts constantly varies during several of the first years of 
life ; but it is not, perhaps, until about the seventh year that all its 
parts are fully formed. 

The brain of the newly-born infant seldom exceeds ten ounces in 
weight ; that of the adult averages about three pounds and a half — 
often something less — but in some individuals, the brain has ex- 
ceeded four pounds, or even four pounds and a half in weight. 

In advanced life, again, the brain diminishes somewhat in relative 
as well as general size, and it has been ascertained, according to 
Desmoulins and Cauzevielh, that it diminishes in specific gravity, 
from one-twentieth to one-fifteenth. It grows rigid in its quality, 
becomes again unequal to the due performance of its functions, as 
it had before been in infancy, though from an opposite cause, and 
second childishness is said to take place. 

The cerebellum is at birth somewhat more advanced in organiza- 

* The presence of phosphorus constitutes an essential ingredient in the chemical 
composition of the brain, (as proved by recent researches,) and the quantity of this 
substance present in the brain of the child, is much less than in that of the adult, 
and again diminishes in advanced life. The brain of the idiot is found to be re- 
markably deficient in this ingredient. 



CEREBRO-SPINAL SYSTEM. 2X 

tion than the brain ; but it is about the period of puberty that the 
relation between the cerebrum and cerebellum undergoes the most 
remarkable change, the latter becoming considerably augmented in 
relative size, being then nearly twice as large, in proportion, as it had 
been at birth. 

The spinal marrow is largely developed, like the brain, in the infant, 
but appears to be more matured in structure, and farther advanced 
in the performance of its functions. 

The general sensibility is acute, and the nervous susceptibility in 
the infant remarkable ; so that all impressions are vividly felt, although 
transient in effect, and sympathetic affections are presented in a very 
aggravated form, and are very prone to occur, constituting a peculiar 
feature in the infant constitution, which may be emphatically said to 
be nervous. The large endowment of nervous matter, and its peculiar 
susceptibility of impression from the softness of its texture, appear to 
confer this quality, which is never to be lost sight of in the treatment 
of infantile disease — a remark as old as the time of Boerhaave, but 
which is nevertheless too frequently forgotten. 

As the infant grows older, the brain, the centre of nervous power, 
becomes capable of perceiving impressions made through the senses. 
Signs of intelligence begin to be manifested : the infant takes notice, 
and becomes sensible of the qualities of bodies, recognizing them 
and exhibiting symptoms of gratification or annoyance. The nerves 
of sensation, however, though freely developed, are as yet but im- 
perfect in their functions, and inadequate to the conveyance of their 
appropriate impressions ; while we find that the apparatus by which 
the external sources of these sensations are supplied, is more or less 
imperfect, and destined to undergo much alteration. 

To notice particular senses, we shall commence with vision, which 
does not appear to exist in the newly-born babe, though the eye is 
fully developed : and it has been ascertained, that perfect images are 
formed on the retina. Vividly illuminated objects seem soon to 
attract notice; but the eye follows or is fixed on them, at first, in an 
apparently passive manner, little dependent on the will. Light is at 
all times agreeable to the infant, which seems naturally to dislike dark- 
ness ; but a very bright light is injurious, as well as annoying, to the 
eye. 

The sense of hearing is as little exercised as that of sight, in the 
first instance. It is doubtful if the young infant can hear at all ; at 
least for some time it does so but very imperfectly ; and that this must 
be the case is manifest, from the deficiency of structure in the exter- 
nal ear, which is as yet ill calculated to collect or receive vibrations 
of sound, the pinna being very inelastic, the tympanum small, and 
its membrane oblique, while a soft matter, little favourable to vibra- 
tion, covers all. 

Taste early exists, and provision is made for its exercise in the full 
development of the mouth ; but probably perception of flavours is 
enjoyed to a less extent than we might at first suppose. The appa- 
ratus connected with the sense of smell, is much less fully formed ; 
and although this sense be manifested early, there is little probability 
that delicacy of perception is early enjoyed by it. 



2 o PECULIARITIES OF INFANTS. 

The absence of speech, or the capability of uttering articulate 
sounds, is a deficiency characteristic of infancy, (as indeed the word 
infant ia implies,) but not to be accounted for by mere anatomical 
examination of the organs of voice, though these certainly are but 
imperfectly developed. The larynx is small, and nearly circular : the 
lips of the glottis, and the superior ligaments, being, therefore, very 
short. This condition of parts, combined with an immature muscu- 
lar endowment, sufficiently accounts for the shrill, feeble tone, and 
wailing cry, peculiar to the infant ; but the acquisition of the power 
of speech, is connected with the advance of intellect, rather than 
alteration of mechanical structure, in this part of the apparatus 
of voice. The gradual alteration going on in the larynx, does 
not become very evident until the period of puberty, when the rima 
glottidis enlarges, the thyroid cartilage, and thyro-arytenoid muscle, 
become elongated, and a change in the tone of voice is consequently 
occasioned. In the male this assumes the deep and grave sound, 
which characterises the full-toned voice of manhood ; while in the 
female little change takes place in the larynx ; and the acute tones 
still remain characteristic of the female voice, which always more or 
less resembles that of childhood. The mechanism on which depends 
the power of articulating intelligible sounds, is more connected 
with the increased growth and power of the muscles of the mouth 
and pharynx, which, even before intellect begins to dawn, become, 
by a happy provision, early developed, being necessary both for 
sucking and deglutition. The infant begins to articulate at from half 
a year to a year old ; and usually speaks plainly, or so as to be under- 
stood by a stranger, at from two to three years of age. 

The general sense of tact, or perception of contact, makes us con- 
scious of the presence of external bodies ; and, to a certain extent, is 
exercised by the whole cutaneous surface, though not in like degree. 
In the young infant, however, the skin does not seem well disposed 
for the active exercise of this power, the papillae being less developed, 
and its structure more gelatinous than in after life. The sense of 
touch, strictly so called — or that perception by contact, in virtue of 
which we not only recognise the presence, but certain of the qualities 
of bodies, — exists only in some organs — almost solely in the hands 
— and is but little developed in the infant. 

Whether the skin be less sensitive or not, the muscular endow- 
ment necessary for the exercise of this sense is but very imperfect, — 
the use of the fingers for this purpose being as yet unknown, or the 
attempts to employ them sufficiently awkward. 

The assistance of muscles is necessary for the exercise of all the 
special senses ; and the imperfection of the muscular apparatus is a 
principal cause of the deficiencies of these senses in the iufant. 



VI. LOCOMOTIVE APPARATUS. 

The organs of locomotion are those that enable us voluntarily to 
come into contact with external objects ; and these organs are but 
little developed in the child, in either of their chief component parts, 
bone or muscle. 



GROWTH. 23 

The osseous system, in particular, is imperfectly and unequally 
developed, varying according to the purposes of its different parts. 
The bones necessary to contain and protect important organs, as the 
bones of the head or chest, are much more advanced in ossification 
than those destined merely for muscular support, or locomotion, — 
which are but imperfectly ossified, or exist as yet only in the form 
of cartilage.* The bones in general are characterised by their small- 
ness of size, redness of colour, and softness of texture, being very 
vascular, and the earthy part not only much less in proportion than 
in the adult bone, but even the animal portion being less firm, in 
consequence of the larger proportion of gelatin. The bones in the 
infant, then, are little calculated, from their formation or structure, 
for the support of the body in the erect posture, or the endurance of 
strong muscular exertion; nor are the muscles themselves better pre- 
pared for such efforts. 

We have already noticed the characters of the muscular tissues of 
organic life, or the involuntary muscles in the infant. Similar cha- 
racters of structure belong to the voluntary muscles. They are pale 
in colour, and easily torn, being soft in consistence, and slender in 
shape, the bellies of the muscles not being yet formed. They con- 
tain less fibrin than in after life, and have their fibres but loosely 
united, the fasciculi not being embraced by fasciae or aponeuroses. 
Similarly imperfect are the tendons and ligaments, or muscular ap- 
pendages. In the child, the irritability of the muscles, or tendency 
to contract, is more easily excited, but less easily sustained, than in 
after life. Hence the motions of the child are quick or sudden, and 
frequent, but fail in capability of effecting powerful action, or 
sustaining continued exertion. 

The first efforts of the infant at voluntary movements are thus 
necessarily imperfect. It begins to attempt walking at about twelve 
months of age, and has generally acquired the power of walking 
alone between the second and third year. But many are the mis- 
chances which such efforts entail ; foreseeing which, nature has 
providently furnished a shield of defence in the yielding and elastic 
cellular tissue, in which the body of the child is so liberally encased. 



VII. GROWTH. 

We have already designated infancy as the period of growth ; and 
this character, which continues during childhood, is sufficiently mani- 
fested by the progressive and rapid advance made in the body at 

* " The most striking fact of this kind," to use the words of Dr. Symonds, in his 
able article "Age," Cyclopaedia of Anatomy and Physiology, "is presented in the 
spinal column. The annular portions of the vertebrae, which form the canal of the 
medulla spinalis, are found strongly ossified at birth : but the bodies of these bones, 
which are to be used hereafter in supporting the weight of the head and trunk, are 
very slightly expanded, and all but devoid of earthy particles; while the processes 
to which the muscles employed in the flexion and extension of the column, after- 
wards contract attachments, are either only shaped in cartilage, or may be said to 
have no existence." 



24 PECULIARITIES OF INFANTS. 

large, and its several organs in detail. The progress of this advance 
is uniform; so that the successive developments of different parts 
observe stated periods and a well-known order. 

In this progress we are most attracted by the advance made in the 
organs of animal life : but the changes which take place in the organic 
functions are not less remarkable, though less noticed ; consisting 
principally of a decrease in activity, if not power, and occurring out 
of sight, so as to be little obnoxious to observation .* 

As the infant grows older, digestion ceases to be so active, and 
the digestive tube so sensitive. Food is less frequently required ; and 
the kind of food may be more varied, a more stimulating variety being 
borne, and necessary. The secretions begin more to resemble those 
of adult life, and the evacuations require less frequently to be voided, 
being no longer passed independently of the will. The involuntary 
muscles generally acquire more tone, grow firmer in structure, and 
deeper in colour, losing their puerile irritability. 

Respiration becomes slower, and the pulsations of the heart less 
frequent, — the respiration gradually parting with the attributes of 
puerility, and the pulse diminishing in rapidity. 

The activity of secretion becomes abated, and the membranes are 
not so vascular or sensitive. Less mucus is secreted naturally, or 
poured out on the occurrence of irritation. The capillary vessels are 
no longer so abundant, nor do the arterial branches preponderate so 
much over the venous. 

As the child advances in age, the activity of the ganglionic system 
of nerves is less manifested, while that of the cerebro-spinal system 
comes more into play ; and the body, gradually losing the characters 
of infancy, begins to assume the attributes of adult age. 

In these various stages of advance, we are particularly struck by 
the progress made in the powers of sensation, perception, and volun- 
tary motion, or in the organs of animal life. Sensation awakens, and 
the senses successively and rapidly expand. Perception is mani- 
fested, and reflection in due time succeeds. Thus endowed, the 
child is competent to voluntary efforts ; and muscular power is pro- 
portionably developed, and brought into action. The several senses 
improve as they are exercised, and mutually aid each other by cor- 
roborating or correcting the impressions received by each. 

Our perceptive faculties are thus brought first into action, and we 
obtain a knowledge of the existence and properties of external objects. 
Memory, " the storehouse of the understanding," becomes furnished, 
and the intellect is supplied with the materials of knowledge, and 
business for thought. 

* In both systems of nerves, sensibility precedes activity, the course or current of 
innervation being-, at first, from sensation to motion, although afterwards the opposite 
often obtains. There is also a certain correspondence between sensation and action, 
but this is more remarkable in the organic nervous system than in that of animal 
life; for in the former, action is directly proportioned to sensation, being, in fact, a 
necessary consequence of it: but in animal life, this relation is uncertain, the result 
not being invariable, but controlled by the brain, through which impressions must 
pass, or in which they originate. (Note to 4lh Edition.) 



GROWTH. 25 

The progress of growth in the organs devoted to the exercise of 
the senses, the intellect, and voluntary motion, is remarkable and 
characteristic, but unequal in advance, and tardy in completion. The 
perfecting of these organs, finishes the process of growth ; and is not 
fully completed until the period of maturity, or near to the meridian 
of life. Perfect development of the bones and muscles, connected 
with the apparatus of the organs of sense, is necessary for the full 
exercise of the several senses, and is not finally completed until long 
after the period of childhood ; nor are the powers of sensation brought 
to perfection before then. The acuteness of the early impressions is 
probably great, whether in consequence of their novelty, or the sensi- 
bility of the nerves : and such impressions seem to be recollected as 
peculiarly pleasurable. But it is only by practised experience that 
the perfection of sensation can be attained, as is remarkably exem- 
plified in the sense of touch. 

The advance in the organs of voluntary motion, — the knitting of 
the frame and development of the muscular power, — constitute the 
most noted feature of growth ; and the completion of these organs, 
the most characteristic attribute of manhood. The form of the 
skeleton, and its several parts, alters much ; and the chemical consti- 
tution of the osseous system, also, undergoes change. The relative 
development of the pelvis and lower extremities, comes to bear a 
better proportion to that of the thorax and the rest of the body. The 
form of the spine assumes more of the alternate curvatures of full 
growth. The shafts of the bones become firmer, and more closely 
united to their heads, and the processes shoot out ; while the quantity 
of calcareous matter gradually increases, until the completion of bony 
growth, when the framework of the muscular system is brought to 
perfection. 

The muscles do not remain stationary while the bones advance. 
Their colour deepens, and the fibres become well defined and firm, 
being developed so as to form the belly, or central fulness ; more 
fibrin enters into their composition. The aponeurotic sheaths, and 
tendinous appendages, have become necessary, and are added. Mus- 
cular exertion now comes into busy operation, but continues to be 
characterised by activity rather than power. The child has a con- 
stant tendency to muscular movement, and loves exercise ; but the 
power is soon expended, and rest is required, — well-concerted, or 
long-sustained, muscular exertion being beyond its capability. This 
is an important moral as well as physical check, the corporeal power 
being limited, and full strength not acquired, until the controlling 
influence of a matured intellect has been provided. 

This brings us to consider the progress of growth in the cerebro- 
spinal portion of the nervous system ; particularly the brain, the 
organ of thought and feeling, and that in which remarkable changes 
takes place. 

As the body elongates, the spinal marrow of course becomes en- 
larged, until it bears to the brain a greater proportion in size than it 
did at birth ; but having been more forward in structure from the 
first, its advance in this respect is less remarkable. 
3 



2(3 PECULIARITIES OF INFANTS. 

The brain grows, and the head enlarges remarkably, within the first 
year after birth — particularly, during the first few months. The 
imperfect state of ossification in the bones of the skull at this period, 
admits readily of the rapid enlargement of the cranium and its con- 
tents ; this being one of the uses of the fontanelles, in addition to the 
facility which they can afford in delivery, by allowing the bones to 
overlap each other, and so diminishing the bulk of the head. Six of 
these deficiencies in ossification are found at birth, the spaces being 
covered by membrane : nor have the sutures yet begun to form. 
The principal of these openings is called the bregma, and is situated 
at the top of the head, between the frontal and parietal bones ; an- 
other is found behind, between the occipital and parietal bones ; and 
of the remaining two, (each of which is double, thus constituting six 
in all,) one in found in the temporal fossa, at each side, the other 
above each mastoid process. The presence of these fontanelles 
(particularly that on the top of the head,) is a source of uneasiness 
to the ignorant, imparting to the hand an uncomfortable sensation, 
as if the brain were devoid of protection ; and improper, and often 
injurious attempts are accordingly made to remove them, by com- 
pressing the head, for the purpose of bringing the bones together. 
But so far from being a cause for alarm, these openings are a source 
of advantage. The effects of blows or falls on the head, (to which 
the infant is so liable,) are thus mitigated, the shock being inter- 
cepted before it has affected the brain ; while, in cases of disease, the 
danger from effusion is lessened by the possibility of quick expan- 
sion thus permitted, and which diminishes the effects of compression. 
These openings gradually close by a natural process, and will be 
found completely united by the fifth year, when the sutures are well 
marked and formed. Occasionally, the fontanelles are later in closing, 
the process of ossification being slow or imperfect ; and this is a 
just cause for uneasiness, having its source usually in a general deli- 
cacy of constitution, often connected with a strumous taint. 

The brain not only increases much in size in the child, but also 
alters sensibly in structure, advancing towards more complete organ- 
ization ; and this remarkably, at the time when signs of intelligence 
begin to be displayed. Prom about the period when the first teeth 
appear, this advance in structure is striking, that in size having been 
before more remarkable. The brain now becomes firmer, more con- 
sistent, and less vascular ; the difference between the medullary and 
cortical portions is more pronounced ; the former is less red, the latter 
deeper coloured ; the convolutions are better marked, and so the 
peripheral surface more extended. The advance in quantity and 
quality continues manifest to the age of seven years, or about the 
period of second dentition, which appears to be on many accounts 
remarkable. The brain has now assumed considerable volume, and 
its structure apparently resembles that of adult life; but after this 
period, advance in structure, and increase of size, may still be ob- 
served, though not so remarkably.* 

The concretions of the pineal gland have begun to form about this period ; and 
they are redder in colour, but fewer in number, than in after life ; in some instances, 
however, they never form. 



GROWTH. 27 

The character begins now to be defined, and some indications of 
the mental endowments of the future man are afforded ; the features 
form, and the physiognomy begins to exhibit traces of a marked dis- 
position. But in regarding the countenance, we must take into 
account the development of the bones and muscles connected with 
the head and face, which occurs about this age : yet the general en- 
largement of the head is not so much connected with the expansion 
of the skull and its integuments, as some insist. When the circum- 
ference of the head, taken above the orbits, does not exceed thirteen 
inches in the adult, idiotcy always attends, according to Gall : and 
Dr. Voisin found, on careful examination, that idiotcy was complete, 
when this measurement varied fromeleven to thirteen inches ; while 
that from the root of the nose over the head, to the occipital spine, 
measured only between eight and nine inches. In the full-sized head, 
the former measurement averages two and twenty inches ; the latter 
fourteen. A very small head is usually accompanied by feebleness 
of character ; but the head may be large, and the person dull or even 
idiotic, — the deficiency existing in the structure or quality, not in 
the size of the brain. 

The advance of growth in the brain does not seem to proceed 
equally, either as to size or structure, in all parts. Vimont notices, 
that the increase of size, during the first months, is most remarkable 
in the parts situated at the base of the skull, and occupying the anterior 
and inferior regions of the frontal bone ; while, of the cerebral con- 
volutions, those soonest acquiring firmness of structure, are placed in 
the lateral and middle parts of the base. All know that the cere- 
bellum does not acquire its full development until about the period 
of puberty. 

The head varies with the progress of growth not only in size, but 
shape, — the different regions of the brain being found to bear a dif- 
ferent relative proportion at different ages — particularly, during 
youth ; while at all periods there exists a certain degree of individual 
peculiarity, and a capability of alteration in size, whether by increase 
or diminution. 

Not less remarkably do we observe a certain order or relation in 
the successive development of the several moral and intellectual 
powers ; which is, doubtless, dependent upon this relative advance 
in size or structure in different parts of the brain, though not yet 
generally confessed to be directly connected therewith, — observa- 
tions for determining this point having been but partially made, and 
the importance of the subject not yet duly appreciated. However 
this may be, it is certain, that the disposition and intellect are gra- 
dually unfolded ; and that attempts to force the one or the other be- 
fore its appointed time and proper progression, are sure to be attend- 
ed with injurious, if not dangerous, consequences. The reason is 
obvious and physiological ; because, what is called the cultivation 
of the mind, is in truth but the exercise of the brain ; and this, like 
every other organ, if over-tasked, will be debilitated or destroyed. 

In noticing the development of the intellectual powers, we see that 
the child observes before he reasons — that the perceptive faculties 



2S PECULIARITIES OF INFANTS. 

come into play before the reflective. The child early observes and 
recollects things, and the qualities and relations of things ; and is 
inquisitive about events. He constantly asks what this or that is. 

But the senses advance still more rapidly than the perceptive 
faculties, and are thus prepared to furnish these faculties with know- 
ledge of the various properties of matter. The differences to be ob- 
served, however, in the power of appreciating these qualities of 
bodies depend on differences in the constitution of the perceptive 
faculties — not of the senses. The eye may see well, and clearly 
perceive differences in size or form, and yet not be able to distinguish 
differences in colours ; the ear that hears best, is not that which best 
appreciates those variations in sound that constitute melody. 

The various degrees of talent exhibited by some children more 
than others, depend much on the different degrees with which they 
are endowed with those faculties that take cognizance of the physi- 
cal properties of things. In these qualities and relations of bodies 
we have the foundation of the physical and natural sciences ; and 
for these sciences (especially the latter), mental capacity exists at a 
much earlier age than seems commonly supposed. 

The gift of language as a mental power, is that which earliest 
attracts attention, and is first cultivated. Hence, facility in this 
respect, with a quick observation, are taken as indications of great 
intellectual capacity. But the reflective faculties must be in full 
operation, to constitute a really good understanding ; and these are 
always the latest to be developed, and often not very liberally be- 
stowed. It is, indeed, upon a due balance between the reasoning 
and perceptive faculties, that the superiority of the intellect will de- 
pend. Where the latter preponderate, they early show themselves, 
and give a quickness of apprehension which, in the child, is often 
taken for superior talent. But the smartest boy does not necessarily 
make the cleverest man ; there must be a full endowment of the re- 
flective faculties, to give depth of thought, or soundness of under- 
standing. When these faculties early preponderate, however, the 
child may be slow in apprehension, and will probably be esteemed 
dull ; but when the period for their exercise arrives, powers will be 
exhibited which had not been anticipated. Peculiarities of disposi- 
tion, moreover, affect these results as much as differences in talent, 
though seldom, if at all, taken into the account. A careless disposi- 
tion will often forfeit all advantages of superior intellect ; while per- 
severing industry may more than compensate for the absence of 
brilliant talents. The child often exhibits (from the earliest age) a 
marked disposition, as it occasionally does some peculiar talent. 
Almost from the moment of birth some infants are observed to be 
peevish, passionate, or obstinate ; while others are gentle and affec- 
tionate, or timid. A determined infant may be seen to rule a weak 
parent, and even exercise an influence over a whole family. A very 
gentle child may never acquire sufficient force of character to make 
his way in the world, no matter how intellectual he may be. 

The higher sentiments, generally speaking, are the more slowly 
developed ; and superior moral powers, as the sense of justice and 



GROWTH. 29 

religion, are among the latest to come into operation, requiring some 
assistance from the understanding for their direction and support. 
Before we are generous we should be just ; but to be just we must 
be wise — knowledge is necessary to justice. 

No doubt can exist that the child is endowed with certain powers, 
moral and intellectual, varying in different individuals, and consti- 
tuting natural differences of character ; but this militates not against 
the necessity for education or training, and the vast influence exer- 
cised thereby ; on the contrary, it serves as a guide and a limitation, 
— pointing out what requires to be cultivated, and what to be re- 
pressed ; and shows us what is possible to be done. 

How important, then, to acquire a knowledge of the primitive 
faculties of man, and the laws by which they are regulated in their 
natural development, or influenced by artificial training. Nor is the 
necessity for such knowledge confined to the system more immediately 
connected with mental manifestation. The same holds good respectr 
ing all the other systems in the body, muscular, circulatory, and 
digestive, as well as nervous ; for without due attention to each, we 
shall not be able to do justice to any, nor secure for the whole its 
best advantages during the period of development or growth. 

With regard to the general growth of the body, and the advance 
in height, weight, and strength, differences arise from age and sex ; 
and these have been accurately investigated by M. Quetelet.* 

According to him, the average weight of the male infant at birth, 
is about half a pound more than that of the female, and the length 
about an inch more ; and the annual growth of the female infant is 
less than that of the male, but her development is more early com- 
pleted. Immediately after birth, the weight of the infant is found to 
diminish ; nor does it begin again sensibly to increase until after the 
first week. 

The growth of the stature is most rapid during the first year, when 
it amounts to nearly eight inches; it is less rapid as the child ap- 
proaches the fourth or fifth year, appearing to diminish in direct 
ratio to the age, up to that time ; the growth in the second year being 
only half that of the first ; in the third year,t only one-third ; but 
afterwards it increases with a tolerably regular progression. 

A remarkable difference is often to be observed in the degree of 
development, or proportional growth of one organ or system of organs 
more than another, and in the consequent predominance of the class 
of functions which this system of organs performs. In some children 
the head is very large, and great liveliness and intelligence are early 
displayed, the cerebrospinal system of nerves being that which pre- 
ponderates ; and this lays the foundation for a particular tempera- 
ment, which, according to the rational view of M. Thomas,^ would, 
in this instance, be the cranial or nervous temperament. 

* Sur l'Homme et le Developpement de ses Facultes, &c, &c. 

t It is a popular observation that the height is never more than doubled after the 
third year, the maximum medium, particularly in females, being attained at that age. 
[Note to 4th Edition.] 

t See Physiologie des Temperamens ou Constitutions, &c, &c, par F. Thomas, 



30 



PECULIARITIES OF INFANTS. 



Iii other children, great muscular power is early displayed, the 
chest is large, the body well nourished, and the complexion florid. 
This constitutes the thoracic, or, as it is more commonly called, the 
sanguineous temperament — the circulatory system predominating. 
The child is strong and active, but not particularly intelligent. 

When the abdomen is very large, and the circulation languid,— 
the child being pale, indolent, and dull, with a large appetite, but 
little activity of mind or body, — the abdominal organs preponderate, 
and the temperament is abdominal or lymphatic. 

The expression of the countenance or form of the features is also 
some indication of the temperament. Thus, the development of the 
forehead indicates the proportion of the encephalon : the part between 
the forehead and mouth is, in general, in harmony with the develop- 
ment of the thorax : while the lower part of the face is in relation to 
the size of the abdomen ; so that in each we have an index of the 
temperament, whether cranial, thoracic, or abdominal. 

Other varietes of temperament exist ; and in some individuals no 
temperament is strongly marked ; or more than one are mixed 
together ; — the mixed temperament existing, when the cavities bear 
an exact proportion to each other. In infancy and childhood the 
abdominal temperament has a tendency to prevail. The nervous or 
cranial becomes more particularly manifest at or after the age of 
seven ; when, as we have seen, the brain attains a full development, 
while the thoracic rather belongs to a later period, when the thoracic 
organs (at first so little developed) begin considerably to increase. 
Attention to this subject is important, as modifying our plan of 
management both in health and disease. 

These varieties of constitution may be born with the child, or 
looked on as hereditary : but they will be much influenced by the 
manner in which the individual is managed ; according as one system 
of organs, or another, is exercised or neglected. The great principle 
that should guide us is, to afford to all and each its proper or appro- 
priate share of exercise or occupation, so as to strengthen and even 
enlarge the weak or ill-developed organs ; while we repress those 
that are disproportionately developed, or over active, by consigning 
them to quiescence. To be enabled to do this, however, we must 
study the subject as physiologists. 

Thus have we, in a brief and summary manner, sketched those 
peculiarities of infancy, a knowledge of which must serve as our 
guide in understanding aright the management of children in health 
or disease. This object we have kept exclusively in view, and re- 
sisted the temptation of pursuing any of these subjects, however 
interesting, further than the end proposed would warrant. 

We have seen the infant presented to us, in the first instance, as 
a mere vegetative being, with the organs of nutritive life preponder- 
ating in development and activity. As growth proceeds, however, 
the little being asserts its claim to a higher order of existence. The 
organs of organic life diminish relatively in importance, while those 
of animal life advance, and ultimately preponderate — the infant 
becomes a rational being. 



MANAGEMENT IMMEDIATELY AFTER BIRTH. 31 

To promote this preponderance, and ensure the mens sana in cor- 
pore sano, is the great end proposed in the rearing and management 
of children. The principles by which we are to be guided in our 
attempts to attain this object, have been already pointed out ; and 
the manner in which these principles are to be carried into effect, will 
constitute a chief part of the subjects treated of in the two ensuing 
chapters. 



CHAPTER II. 

MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. 

In the consideration of the subject of this chapter, we shall adopt 
the division already made, into the two epochs of infancy and child- 
hood ; and shall, therefore, first proceed to consider the management 
of the infant directly after its birth. 

I. MANAGEMENT IMMEDIATELY AFTER BIRTH WASHING AND 

DRESSING. 

Let us suppose a healthy child to be placed in our hands immedi- 
ately after birth : the duty of the accoucheur having been duly per- 
formed, any mucus, or other matter likely to obstruct its breathing, 
has been removed from its mouth, and the cord has been tied 
and divided at the distance of three or four inches from its navel. 
The young being will be observed to cry stoutly, and to move its limbs 
in such a manner as forcibly to convey to us the impression that it is 
suffering pain, which we can readily account for, when we recollect 
that it has experienced a sudden transition of temperature, from the 
heat of the mother's body, about 9S°, to that of the atmosphere, 
which, at the highest, will seldom exceed 70°. The production of 
pain, however, is but a necessary consequence of the access of air to 
the surface of the body ; which in itself is highly beneficial, exercis- 
ing, as we learn from the ingenious researches of Dr. Edwards,* a 
vivifying influence, well calculated to counteract the greater or lesser 
degree of insensibility induced by the pressure to which the brain is 
subjected during birth. The pain, also, by exciting the infant to cry, 
contributes materially to the perfect filling of the lungs with air ; the 
non-effecting of which, as we shall subsequently find, is not unfre- 
quently attended by fatal results. Such are the good effects of ex- 
posure to cold ; it should however be but momentary, as its continu- 
ance would certainly be productive of the worst consequences to the 
well-being, and even existence of the child. 

" Instinct," says Dr. Edwards, " leads mothers to keep their infants 
warm, though philosophers, by more or less specious reasoning, have, 

* Dr. Edwards on the Influence of Physical Agents on Life. Translated by 
Drs. Hodgkin and Fisher. (Published in the Select Medical Library.) 



3 o MANAGEMENT OF CHILDREN. 

at different times, and in different countries, induced them to abandon 
this guide, by persuading them that external cold would fortify the 
constitutions of their children, as it does those of adults." To this 
distinguished physiologist we are indebted for the observations, that 
the heat of mature infants at birth, is from 3° to 5° less than that of 
adults — varying between 93° and 95°; that the heat of premature 
infants is still less ; and that the power of producing heat being, in 
all young animals, at its minimum at birth, they have not the same 
capability, as adults, of resisting a diminution of their temperature, 
from exposure to cold. From Dr. E.'s discoveries, indeed, we are 
fully warranted in concluding that the philosophers of whom he 
speaks are in the wrong ; and that nature has, with her usual wis- 
dom, conferred a proper instinct upon mothers, in teaching them to 
keep their offspring warm. It is for us, therefore, immediately upon 
taking charge of the newly-born child, to have it well wrapped up 
in soft, warm flannel; to take care that, in cold weather, it shall be 
dressed in the neighbourhood of a comfortable fire ; and that, during 
the operation, it shall not be unnecessarily exposed to cold.* 

When we examine more carefully the body of the infant, we shall 
find that it is more or less covered with a white, greasy, or curd-like 
substance. This is denominated the vernix caseosa, and appears to 
be provided for the purpose of defending the tender skin from the in- 
jurious effects of the warm, aqueous fluid in which it floats while in 
its mother's womb. After birth this coating has no useful purpose 
to serve; and would be injurious, by obstructing the pores of the 
skin, and by intercepting the vivifying influence of the air of which 
we have already spoken.t It is, therefore, advisable to remove it ; 
and, accordingly, the first act of the nurse is, to wash the new-born 
child. The washing should be performed with warm water, and a 
fine sponge, and as the soft bones of the infant render it unfit to bear 
much pressure from the hands, the operation will be most safely and 

* The views of Dr. Edwards have been practically confirmed by some observa- 
tions of Dr. Milne Edwards, and Dr. Villerme. It is the custom in France, to 
convey infants, within a few hours of their birth, to the office of the mayor of the 
commune, in order that their birth may be registered ; and Drs. E. and V. discovered 
that the proportion of deaths, within a very limited period after birth, compared 
with the total births, was much greater in winter than in summer, — in the northern 
and colder, than in the southern and warmer departments, — and in parishes where 
the inhabitants were scattered over a large surface of ground, than in others, where 
they were more closely congregated round the mayor. 

f If any authority were wanting for the removal of the vernix caseosa, we have it 
in the practice, which obtains universally among animals, of licking their offspring 
immediately after birth. [Note to 1st Edition.] 

In a note by the German translator of this work, we find Oesterlen (CEtiol. und 
Pathol, der Krankheiten neugeborner Kinder. Heidelberger Klinische Jlnnalen Iter Band 
Istes Heft 1831), quoted in support of a different view of this subject. This author, 
it appears, is of opinion that the chief use of the vernix caseosa is found subsequent 
to birth, and that it is designed to protect the skin from the overstimulating effects 
of the oxygen of the atmosphere. He states that premature children have a smaller 
quantity of this covering than those born at the full time, and that the deficiency is 
in proportion to the immatureness. Such has not been the result of our observations, 
nor have we noticed the ill consequences which he attributes to the removal of the 
vernix caseosa, viz., aphthae, jaundice, and ophthalmia. [Note to 4th Edition.] 



MANAGEMENT IMMEDIATELY AFTER BIRTH. 33 

conveniently effected by placing the body and limbs in a basin con- 
taining a sufficient quantity of water to cover them, while the head 
is suffered to rest upon the left arm of the nurse. The eyes should 
be washed with particular care, and clean water used for this purpose, 
as the allowing of impurities to remain in contact with these tender 
organs is the most common cause of the dangerous ophthalmia of 
infants. All extraneous matters should also be removed from the 
folds of the skin in the groins, arm-pits, &c. ; but no force likely to 
hurt the surface should be employed, nor need any extraordinary 
anxiety be felt for the perfect removal of the vernix, as it never fails 
to dry and scale off in a day or two : we have not found soap to be 
required, although it is recommended by many writers. In this 
country, where whiskey is in universal use, the nurses generally 
employ a little of it for washing the child's head, under the idea that 
it prevents the taking of cold. This practice is certainly not a neces- 
sary one in ordinary cases ; but at the same time, it does not appear 
to be attended with any injurious consequences : and when we can 
say so much for any popular custom, it is as well to let people have 
their way, and direct our attention the more closely to the prevention 
of such interference as may be really prejudicial. 

[Even if the practice could be viewed as one productive of neither 
beneficial nor injurious effects, it is better that the physician should 
discountenance it: but as washing the head of a new-born child with 
ardent spirits must produce more or less irritation of the scalp — 
especially where the application of the spirits is repeated daily, as we 
have known it to be, for weeks or even months — the custom should 
be denounced as one decidedly prejudicial. — C] 

The washing having been accomplished, with as little delay as pos- 
sible, and the surface carefully dried with a soft napkin, the next 
business of the nurse is, to dress her charge. This process is com- 
menced by an arrangement for the protection of the remnant of the 
navel string. The cut surface of this should be carefully examined, 
lest, as frequently happens, secondary bleeding should take place, in 
consequence of the loosening of the ligature, dependent on the oozing 
out of the gelatinous fluid, which makes the bulk of the cord. This 
occurrence is most likely to take place when the cord is particularly 
thick ; and the gelatinous fluid very abundant, as the pressure of the 
ligature is then less directly applied to the vessels ; when hemorrhage 
has taken place, a fresh ligature must be applied firmly, and its ends 
cut off close to the knot. The cord is then to be drawn through a 
small circular hole, cut in a piece of old linen, about four or five inches 
in diameter, which is to be gently folded around it. In the prepara- 
tion of this envelope, nurses are particularly anxious to have it ex- 
tremely dry and warm. It is always held carefully to the fire, and 
sometimes even scorched, before they will permit its application — a 
prejudice which is certainly harmless, and probably but one indica- 
tion of the general instinct which teaches them that a new-born infant 



3 4 MANAGEMENT OF CHILDREN. 

requires its heat to be carefully husbanded.* The cord, thus enve- 
loped, is to be placed flat on the child's abdomen, and secured there 
by a band of thin flannel, five or six inches broad, and long enough 
to go twice round the body. The chief use of this band is, to support 
the navel-string and its covering : we cannot think that it is required, 
as Dr. Deweest supposes, as a support to the abdomen ; indeed, it 
never should be applied so as to make any pressure upon that cavity ; 
and on that account, it is well to have it made of the thinnest flannel, 
cut diagonally or bias, so as that it may be perfectly elastic. In fast- 
ening it, pins are usually employed ; but the fewer of these used in 
dressing an infant, the better ; and it would be well, if we could have 
strings substituted for them in every possible case. The further 
dressing of the body of the child, is very much a matter of fashion, 
with which the physician has little to do further than to see that the 
clothing is light, soft, and sufficiently warm, and not calculated to 
place any restrictions upon the movements of the chest, abdomen, or 
limbs. It would now be a work of supererogation, in this country, 
to denounce the swaddling of the limbs practised in former times ; but 
we cannot too forcibly impress the necessity of avoiding all constric- 
tion or pressure upon the chest or abdomen. The due performance 
of respiration is of the first importance to the young as well as to the 
adult animal, and this will be materially impeded by any restriction 
upon the free motion of the ribs or diaphragm such as would be occa- 
sioned by tight bandages upon the body of the child. The arrange- 
ment of the head-dress must be conducted upon principles similar to 
those which guide us with respect to the other clothing : the head is 
to be protected from the cold air by a moderately thick, muslin cap, 
but so as that it shall neither suffer compression, nor be placed in a 
constrained position. Over all, a thin flannel shawl is to be wrapped 
in such a way as will not impede the free access of air to the mouth, 
or hamper the extremities, so as to prevent their spontaneous move- 
ments. The infant is then to be placed in a cradle or bed, so situated, 
as that it shall not be exposed to draughts of cold air ; and that, 
while it is not absolutely in the dark, still its eyes may be protected 
from a strong light, which, as yet, they are unable to endure : thus 
placed, it will usually fall asleep, and remain so for several hours, 
until awakened by the calls of hunger. 

[The use of a cap for young infants is unnecessary — as the head 
may be effectually protected from the effects of cold without it. Caps 
are much more likely to produce injury than benefit, and we are 
happy to find that they are rapidly falling into disuse.— C] 

* As a curious instance of this dread of abstracting heat from the child, we often 
find the peasants of this country carefully warming the scissors, before using it for 
the division of the cord. It is easy, and, no doubt, appears scientific, to ridicule 
popular customs and superstitions ; but would it not be more discreet and philoso- 
phical, to endeavour to discover their origin from some instinct to which thev mav 
generally be traced 1 J J 

f On Physical and Medical Treatment of Children. London, 1826.. 



FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. 35 

II. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. 

During foetal existence, the various organs designed for the per- 
formance of digestion, produce a greater or lesser quantity of their 
peculiar secretions ; and, as there is no exit provided for these, they 
accumulate in the intestines of the child, constituting the dark green, 
or brownish, pitch-like substance denominated meconium. By many 
persons even at the present day, the retention of this meconium is 
supposed to exert a most baneful influence upon the health of the 
child ; and it is believed that no time should be lost in effecting its 
speedy removal. Accordingly, very few children in this country are 
fortunate enough to escape being dosed with castor oil, immediately 
upon their arrival in the world : and many are obliged to undergo 
the additional peril of having a quantity of calomel forced down their 
throats. Neither of these practices, however, is constantly neces- 
sary, and the last is positively injurious : the delicate mucous mem- 
brane of the child's intestines, only fitted for the reception of the 
mildest nutriment, is always injured by the operation of a medicine 
so active and so irritating as calomel. To the milder action of castor 
oil, the same objection does not apply ; and where the abdomen of 
the child is full, and no evacuation takes place for five or six hours 
after birth, it will usually be found advantageous to administer half 
a drachm of oil, provided we can procure it fresh, and free from 
rancidity.* We are, however, decidedly of opinion, that it is better 
and more natural to allow an infant to sleep quietly for five or six 
hours after birth ; and not, before that period, to disturb it, or irritate 
its stomach, by the administration of anything whatsoever. Those 
who advise the immediate employment of purgatives, assert that such 
practice is consistent with the plans of nature,t inasmuch as they 
suppose the milk first secreted by the mother (or colostrum, as it is 
termed), to possess a purgative property. The argument is obvi- 
ously a contradictory one ; for, if nature herself provides a purgative, 
why should we seek to supersede her efforts by artificial means ? 
The fact, however, of the first milk being purgative, is not proved, 
and is altogether denied by some.J It is probable that it possesses 
no specific purgative quality, but excites the intestines merely by 
mechanical distention, and so in effect produces expulsion of the 
meconium, as other food is found to do, in cases in which it is given 
in consequence of the secretion of milk not being established in the 
mother's breasts, for two or three days after labour. 

So much for medicine, immediately after birth ; and upon the 
same principle, viz., that sleep is what the infant most requires, we 
do not think it necessary to give it food, for some hours. Should 
the mother be able to supply the natural nutriment at the end of 

* This is a matter of considerable importance. In the interior of Germany, where, 
inconsequence of the long land-carriage to which it is subjected, castor-oil is almost 
universally rancid, this purgative is considered as peculiarly irritating. [Note to 
3d Edition.] 

+ Dewees. 

% Jdrg, Handbuch zum Erkennen u. Heilen der Kinderkrankheiten. 



36 



MANAGEMENT OF CHILDREN. 



eight or ten hours, or even earlier, as is often the case, we think th 
infant should then be applied to the breast; and that it is highl 
desirable to avoid giving, in the interim, any other food whatsoevei 
Should the secretion of milk not be perfectly established for two o 
three days, as sometimes happens, the child will be cross and evinc 
signs of hunger, and we shall then generally find it necessary to give 
small quantity of thin gruel, mixed with a little milk. Even in thes 
cases, Professor Jorg recommends, that nothing should be given bu 
a few teaspoonfuls of lukewarm water ; and we happen to knov 
that such is his practice, without any bad results, in the Lying-i: 
Hospital of Leipzig. Notwithstanding this, however, should it no 
be practicable to have the child suckled within ten or twelve hour 
after birth, we think it advisable to give, every five or six hours, : 
few teaspoonfuls of such food as has been mentioned above, but t 
desist immediately upon a nurse being procured, or the mothe 
becoming herself capable of supplying sufficient nourishment. 

Having premised thus much respecting the attentions required b; 
the infant immediately upon its entrance into the world, we sha 
now proceed to consider its further management with regard to fooc 
cleanliness, clothing, sleep, exercise, medicine, and the action upo. 
it of physical agents, as light, air, and heat. 

III. FOOD IN THE FIRST PERIOD. 

It is unnecessary to go at any length into the question of the pro 
priety of mothers nursing their own children; the weight of th» 
moral and physical considerations which leave no choice as to th< 
propriety of obeying the dictates of nature, being now universally 
acknowledged. Women are not, at least at the present time, and ii 
these countries, the unnatural deserters of their offspring that sys 
tematic writers would lead us to suppose ; and, we think, mos 
experienced physicians will join us in declaring, that our duty les 
frequently is, to urge maternal nursing, than to explain, and ever 
enforce, in individual instances, the exceptional causes whereby 
nature herself sometimes renders it impossible or inexpedient to com 
ply with her general law. We are, in fact, oftener obliged to sav< 
an infant from destruction, and a delicate mother from injury, b] 
forbidding ineffectual attempts at nursing, on the part of the latter 
than we are called upon to remind a robust and healthy parent o 
the urgency of the natural claims upon her. We shall therefore 
assume, as a general rule, that all mothers should nurse their owi 
children ; and merely indicate those cases in which it become; 
necessary to substitute another mode of rearing the child. 

Women who labour under any mortal or weakening disease, — a: 
phthisis, hemorrhages, epilepsy, &c, — are obviously disqualifiec 
for the office of nurse ; some, who are in other respects healthy 
have breasts incapable of secreting a sufficient supply of milk, anc 
this may be temporarily the case with one child (especially the first) 
while upon other occasions the same individuals make excellem 
nurses. In other instances the breast may perform its function* 



FOOD IN THE FIRST PERIOD. 37 

well, but the nipple may be naturally so small, or may be so com- 
pletely obliterated by the pressure of tight stays, as not to admit of 
its being laid hold of by the child. These are actual, physical 
hindrances to nursing. Again, women may, and in the higher 
classes frequently do, possess such extremely sensitive and excitable 
temperaments as will render it imprudent for them to suckle their 
own children. Frightened and excited by every accidental change 
in the infant's countenance, and inordinately moved by the common 
agitations of life, such persons are kept by their own tenderness, 
and over-anxious desire to do their duty, in a state of continual 
fever, which materially interferes with the formation of milk, both 
as to quantity and quality. Women, also, who become mothers for 
the first time at a late period of life, have seldom the flexibility of 
disposition, or the physical aptitude for secretion of milk, required 
to constitute a good nurse. Another disqualification for nursing we 
must notice, although we hope and believe that it is rarely observ- 
able among our countrywomen : if women of fashion are not con- 
tented to give up their engagements in society in favour of their 
domestic duties, it is better for them not to undertake the latter — 
" In this matter," says Wendt, " it is better to do nothing than only 
half." 

We have already stated, that the child should be put to the breast 
as soon as the latter contains anything for it to extract ; this gene- 
rally happens when the mother's system has been relieved, by sleep 
and ten or twelve hours' rest, from the fever which is always more 
or less attendant upon labour. Unless there has been some secretion 
of milk, it is better not to apply the child, as it becomes disappointed 
by continued ineffectual attempts at obtaining nourishment, and 
there may subsequently be some difficulty in getting it to engage 
seriously in the business of sucking.* As soon, however, as it has 
fairly commenced, it will require no other food ; and if the mother 
be a good nurse, she should be able to support her infant indepen- 
dently of artificial nutriment, during at least two-thirds of the period 
of infancy, — that is to say, until the seventh or eighth month. 
About that time the teeth usually begin to appear, indicating that 
the digestive system is assuming a capability of doing more work 
than it was adequate to at first ; and, accordingly, we should then, 
taking the hint from nature, begin gradually to train and exercise its 
powers. The suckling of the infant, which during the first months 
should be performed at regular intervals of about four hours, should 
now be repeated not more than three or four times during the day 
and night ; and twice during the same period some artificial food 
should be given. This at first may consist of soft bread, steeped in 
hot water, with the addition of a little sugar and fresh cow's milk ; 

* We have heard the propriety of the advice given above, called into question. 
Practical men will, however, have no difficulty in understanding the advantage of 
preventing the disappointment to the child, and the injury to the nipple itself, some- 
times occasioned by protracted drawing at an absolutely empty breast : this is the 
utmost extent of delay which we wished to recommend, and to this recommendation 
we must still adhere. [Note to 2d Edition.] 
4 



3S MANAGEMENT OF CHILDREN. 

subsequently some light broth, free from fat and vegetable matters, 
may be given once during the day. With respect to the rnode of 
feeding at this period, the spoon will be the best vehicle, as it is an 
object to give food somewhat more solid than could be drawn through 
the sucking bottle. The child, however, should not be placed hori- 
zontally on its back, and gorged until it is rilled to the throat, as is 
often done ; but its head should be kept elevated, and its actions be 
carefully attended to, so that we may know, and at once stop, the 
moment it appears to be satisfied. 

During the first five or six months, the infant must be suckled 
during the night as well as the day, but this should be done at the 
regular intervals of four hours ; and if it sleeps with the mother or 
nurse, the nipple should not be allowed to remain in its mouth, as it 
is not our object to keep the stomach constantly full, but to give it 
time, when filled, to digest its contents. A child nursed as we have 
recommended, will be found to awaken, with a good deal of regu- 
larity, at the proper periods for its meals. During the process of 
weaning, the intervals between the times of suckling at night, may 
be at first gradually lengthened ; but in order to ensure unbroken 
rest, at a subsequent period, both for the attendants and the child 
itself, it is very desirable not to accustom it to receive any artificial 
nourishment during the hours proper for sleep. 

In nursing, the infant should be put alternately to each breast ; as 
a neglect of this precaution will frequently be followed by an un- 
equal lateral growth of the body, limbs, and even head ; and some- 
times by squinting. Such deformities (all except that last named) 
are commonly not permanent ; disappearing as the child grows ; but 
it is better to avoid them in the first instance. 

We have been hitherto supposing the mother to be a perfect nurse, 
and the relative supply and demand to be well adjusted between her and 
her infant ; but these are not exactly the cases which we always meet 
with in practice. We shall frequently have a demand greater than 
the supply, long before the seventh or eighth month ; and in such 
instances, we shall be obliged to give food at an earlier period, and 
often find it to agree well, if its kind and administration be regulated 
upon the rules just laid down. The great maxim to be observed is, 
not to let the infant want nourishment which will agree with it. 
If this can be furnished by the mother alone, so much the better ; if 
the deficiency'can be supplied by artificial food without the infant 
suffering, there will be no necessity for making any further change : 
but if neither of these conditions obtain, we must have recourse to a 
strange nurse. 

As we have stated it to be desirable, that as much as possible of 
the infant's nourishment should be derived from the nurse, it of course 
becomes an object to render our source of supply as available as may 
be ; and we are, therefore, legitimately called upon to consider how 
this may be done most efficiently. The grand secret, in a word, is, 
to keep the nurse in good health ; if we succeed in this, we render 
the milk, both as to quantity and quality, as good as it can be pro- 
duced by the individual. Now, how is this to be done ? Is it by 



CHOICE OF A NURSE. gg 

overloading the stomach by a mass of indigestible food and drinks, 
and keeping the system under a continued fever of digestion ? or, is 
it not rather by allowing the person to live, as much as possible, in 
the manner customary with her, supposing that to be one which has 
hitherto preserved her in good health, — permitting her to eat her 
usual meals, which she will probably do with increased appetite, and 
not inculcating upon her the necessity of taking drinks more stimu- 
lating, or in larger quantities (relatively with her probably increased 
consumption of food), than she has been in the habit of using ? With 
hired nurses, it is especially necessary to act upon the principle just 
laid down ; for these persons, coming from the scanty table of their 
own homes, are apt to indulge their appetites, from mere novelty, if, 
as is usually the case, their employers show any disposition towards 
the encouragement of a stall-feeding system. Nurses should not be 
kept upon any one description of food exclusively, but should have, 
as is natural, a wholesome, mixed, animal and vegetable diet, with 
or without wine, according as they may have been accustomed to 
live ; but we may, perhaps, allow them, with advantage, somewhat 
of an extra, though never an unreasonable quantity of malt drink, 
providing always that it be found to agree with their digestive system. 

[Wine and malt drinks are neither proper nor necessary additions 
to the diet of nurses. A healthy nurse requires nothing beyond good 
wholesome food of easy digestion, and water as a drink. — C] 

The catemenia, in some instances, appears in a nursing woman, 
and, where it does, is likely to interfere with the thriving of the child 
Whenever, therefore, we find an infant becoming thin, weakly and 
cross, without any sufficient cause being assignable, we should inquire 
into this circumstance, and if a change has occurred, it will generally 
be found advisable to procure another nurse ; or to anticipate the 
time of weaning. 

Irritability of temper, and indulgence in passion, interfere with 
the secretion of milk to such an extent, that a child has been known 
to be attacked with convulsions immediately after being suckled by 
a nurse, who was at the time suffering under the effects of a fit of 
anger. A knowledge of this circumstance influences many persons 
to indulge nurses in the most extravagant whims, lest their temper 
should be crossed, and the child thereby injured. Irritable persons 
are, unquestionably, unfitted to nurse or manage children ; but we 
apprehend, that over-indulgence is not the way to improve temper : 
and as we fear that the most learned diatribe from us, would have 
little efficacy in supplying a good disposition where Providence has 
not created it, we shall not pursue this subject farther. 

IV. CHOICE OP A NURSE. 

When circumstances prevent a parent from suckling her own child, 
it is important that we should have some principle to guide us in our 
selection of a strange nurse. Medical men are constantly asked for 



40 MANAGEMENT OF CHILDREN. 

an opinion upon this subject, aud we shall therefore lay down a few 
rules, which may be useful in enabling us to form one. The great 
thing we have to look to is, to ascertain that both woman and child 
are in good health ; and of this we must endeavour to judge from the 
following signs: — The woman's general appearance and form 
should be observed ; and they ought to be such as betoken a sound 
constitution. Her skin should be free from eruptions ; her tongue 
clean, and indicating a healthy digestion ; her gums and teeth sound 
and perfect ; the breasts should be firm, and well formed, — not too 
large or flabby, — and with perfect, well-developed nipples. We 
should see that the milk flows freely, upon slight pressure ; and we 
should allow a little of it to remain in a glass, in order that we may 
j udge of its quality.* It should be thin, and of a bluish-white colour ; 
sweet to the taste ; and when allowed to stand, should throw up a 
considerable quantity of cream. 

A nurse should not be old ; but it is better that she should have 
had one or two children before, as she will then be likely to have 
more milk, and may also be supposed to have acquired experience 
in the management of infants. The more recently the nurse's own 
confinement has taken place, provided she has recovered from its 
effects, the better, as we may count upon her services so much the 
longer. It is, however, not generally a serious objection should two 
or three months have elapsed after that event. Having examined 
the mother, we must next turn to the child, which should be well 
nourished, clean, and free from eruptions, especially on the head and 
buttocks. We should, also, carefully examine its mouth, to ascertain 
that it is free from sores or aphthae. If both woman and child bear 
such an examination as we have mentioned, we may, with tolerable 
security, pronounce the former to be likely to prove a good nurse.t 

V. ARTIFICIAL FEEDING. 

What we have already stated as to the management of an infant's 
food, negatives altogether the question of the propriety of ever choosing 
to rear a child entirely by artificial feeding. Certain cases, however, 

* N urses who have not a good supply of milk will, occasionally, be found to adopt 
a practice commonly employed with milch cows when brought to market, and called 
by the cattle dealers stocking ,- that is, they allow the milk to accumulate in their 
breasts for several hours before presenting themselves for examination, so as to 
cause the examiner to believe that they are very abundantly provided. Young prac- 
titioners should be especially on their guard against this deception. 

| The following is the beau ideal of a good nurse, according to Wendt. Some of 
its Germanisms may amuse. "Youth, fulness of health, plenty of milk, and a 
good build of breasts and nipples — a rather phlegmatic temperament, — a quiet 
disposition, and no inclination to sensuality or dissolute habits, — a white, delicate 
skin, traversed by blue veins, and covered with freckles, — fair or reddish hair, 
large blue eyes, sound teeth, a fresh breath, a clean skin, no disagreeable odour, no 
unnatural discharges, a bluish-white, — rather thin, than thick and tenacious milk, 
which, dropped upon the thumb-nail, flows off rather quickly, — it should have no 
smell, and a mildly-sweet taste, — along with these, large and firm nipples, a cleanly 
person, and a harmless temper, — form the ideal of a good nurse." — Die Kinder- 
krankheiten syslematisch dargestellt von Dr. Johann Wendt. Wien, 1827, 2tc 
ausgabe. 



ARTIFICIAL FEEDING. 41 

occur, in which we have no alternative. Peculiar circumstances may 
preclude the possibility of procuring a nurse ; or an infant, whose 
mother is incapable of nourishing it, may be the subject of some 
contagious disease, to contamination by which, we cannot, in common 
honesty, permit a stranger to be exposed. The necessity of resorting 
occasionally to artificial feeding, obliges us, therefore, to consider how 
we can render it least injurious, for such is really the question ; 
although, we do not mean to deny, that in certain instances extremely 
healthy children have been reared in this way. These are, notwith- 
standing, but exceptions ; for a very extended experience, in different 
countries, has proved that spoon-feeding is generally unsuccessful. 

The kind of artificial food proper to be employed, forms the subject 
of our first inquiry ; and, as a general rule, we may say, that it should 
be as like the natural nutriment as possible. This rule, however, is 
easier laid down, than acted upon ; "for nature," says Dr. Prout, 
" will not permit the chemist to officiate as her journeyman, even in 
the most trifling degree.* In the present state of our knowledge, 
then, it is vain to attempt any preparation, upon chemical principles, 
of a food resembling human milk. It will be better to be satisfied 
with employing the food of some other young animal, and modifying 
it, so as to make its sensible properties, as nearly as possible, similar 
to the milk in question. For this purpose, good cow's milk is usually 
the most convenient ; and as it is thicker and whiter, and not so 
sweet as human milk, we may add to two parts of it, one of very 
thin barley water, and sufficient white sugar to make the necessary 
increase in sweetness. Asses' milk approaches more nearly, in sen- 
sible properties, to what we require ; but it is richer, and requires to 
be diluted with about a third part of water. So modified, it maybe 
used, if the cow's milk disagrees, or it can be conveniently procured. 
As the child becomes a little older, thin bread pap, made as we have 
already directed,! may be advantageously employed ; and it will 
also be advisable to give, occasionally, some light beef or chicken 
tea. In managing spoon-feeding, all our ingenuity will frequently 
be required for varying the kinds of food ; as one which agrees well 
with the infant at first, may, after a little, derange the bowels, — 
producing acidity, gripes, and purging, or perhaps costiveness. Thus, 
prepared barley, dressed with water and unboiled milk, will some- 
times purge, — an effect which may be obviated by having the milk 
boiled. In other cases, we must employ arrow-root, for a short time, 
for the purpose of restraining the bowels, and again recur to the barley 
when costiveness has been produced. A great matter is accomplished, 
if we can prevent the production of acid fermentation in the stomach 
and bowels ; and, on this account, we must be most particular in 
requiring every article of food to be freshly prepared before use, and 
in enforcing the strictest attention to cleanliness with respect to every 
vessel employed. All kinds of food should be used tepid or luke- 
warm ; that is, at about 96°, or 98°, F., the natural temperature of 
milk, as it would be obtained from the breast by sucking. 

* Gulstonian Lecture, 1831. f Page 37. 

4* 



42 MANAGEMENT OF CHILDREN. 

Our second inquiry relates to the mode of administering artificial 
food. This may be accomplished either with the spoon or sucking- 
bottle.* The former has the advantage of leaving less opportunity 
for uncleanliness, as a spoon is easily washed, and its condition at 
once perceptible ; while the bottle may appear clean, and yet contain 
a leaven of acidity, which will do material injury. On the other 
hand, the bottle has the advantage of giving out the food in a mode 
somewhat analogous to that employed by nature ; with it the child 
has some trouble in procuring what it wants, and will therefore not 
be likely to take too much ; the action of sucking must also be prac- 
tised, whereby a degree of pressure is made upon the child's salivary 
glands, and the necessary secretion from these organs, in all proba- 
bility, usefully promoted. In the earlier periods, we think, the bottle 
possesses, in these respects, decided advantages ; but while using it, 
too much precaution cannot be taken to secure cleanliness. No food 
should ever be allowed to remain in it after the infant has been fed ; 
and there should always be two bottles in the nursery, in order that 
one may be exposed to the air, and dried, while the other is in use.t 

VI. WEANING. 

The time of weaning, we have already intimated, should be that 
indicated by nature, (that is to say, between the seventh and twelfth 
months in ordinary cases,) when, by providing the child with teeth, 
she furnishes it with the means of obtaining nourishment from sub- 
stances of a somewhat solid form. The mode of weaning may be 
easily deduced from the rules which we have laid down for the 
feeding of the infant. If it has been gradually accustomed to a dimi- 
nished supply of maternal, and an increase of artificial food, weaning 
will be an easy process, and a great deal of suffering will be spared 
both to parent and offspring. No violent change should be made ; 
and by proceeding gradually, the child will come to prefer artificial 
food contemporaneously with the failure of the maternal supply. 
This is what the term weaning imports, and this is the mode in which 
U should be accomplished, 

VII. FOOD IN THE SECOND PERIOD. 

For some time after weaning, the child's food should consist of 
those materials which we have mentioned as proper during the latter 
months of suckling. Regularity in the times of feeding, is probably 
ot nearly as much importance as the quality of the food itself. No 
definite rules, however, can be laid down, as to particular hours, as 
much must be dependent upon the habits of the child, and of its 

nri*fi, TheSe b0 ! tleS . have a narrow neck ' about the size of the ni PPle, with a small 
sack. :ZT% W £u a teat u of u w J Mh ^ sh ammy leather, through which the infant 
sucks the food I hey can be had at any druggist's, ready for use. 
and ohp^f \ -♦ BrUck ,e*au, has written a book to prove that goats are the best 
ktotm 8 Toan^ n n Se ^- *•*"" would ^difficult to introduce the practice 
into this country,~£ te Ziege als beste u. wohlfeihte Saugamme, 1816, 2r thtil 1819 



FOOD IN THE SECOND PERIOD. 43 

guardians, as to sleep, &c. ; but the general principles should, under 
all circumstances, be observed, of permitting no variation, from day 
to day, in the time for the different meals, and of not breaking in upon 
these by giving food at irregular periods ; while, at the same time, 
protracted fasting must not be allowed. During the day-time, about 
four hours is quite sufficient interval between any two meals : this 
will give time enough, in children, for the stomach, and commence- 
ment of the small intestines, to perform their offices in the process of 
digestion, and allow the former an opportunity of recovering energy 
after the discharge of its function.* It is better not to allow a child 
to acquire a habit of being fed during the night, as uninterrupted 
sleep is what they then require most ; to ensure which, it is neces- 
sary that the stomach should be in a state of comparative rest. Per- 
haps, the best mode in which we can illustrate our ideas with respect 
to the plan upon which a child should be fed, will be, to describe 
specifically a day's feeding of a healthy child, — premising that we 
do not mean to enforce a literal observance of certain hours, &c, 
specified, but merely to give an example of the working of the prin- 
ciples we have laid down. 

A healthy child, of two or three years old, commonly awakes 
hungry and thirsty, at five or six o'clock in the morning ; sometimes 
even earlier. Immediately after awaking, a little bread and sweet 
milk should be given to it, or (when the child is too young to eat 
bread) a little bread pap. The latter should be warm ; but in the 
former case, the bread may be eaten from the hand, and the milk 
allowed to be drunk cold, as it as well, at this meal, to furnish no 
inducement for eating, beyond that of hunger. After eating, the 
child will generally sleep again for an hour or two ; and about nine 
o'clock, it should get its second meal, of bread softened in hot water, 
which latter is to be drained off, and fresh milk, and a little sugar, 
added to the bread. Between one and two, the child may have 
dinner, consisting, at the younger ages, of beef, mutton, or chicken 
broth (deprived of all fat), and bread. When a sufficient number of 
teeth are developed to admit of chewing being performed, a little 
animal food, as chicken, roast or boiled mutton, or beef, not too much 
dressed, should be allowed, with a potato or bread, and some fresh, 
well-dressed vegetable, as turnips or cauliflower. After dinner, some 
drink will be requisite ; and a healthy child requires, or indeed 
wishes for, nothing but water. Light, fresh table beer, would not 
be injurious to a child of four or five years old; but it is unnecessary, 
and no advantage would, in this instance, result from the creation of 
a new want. a Between six and seven o'clock, the child may have 

a [Independently of the appetite for stimulating drinks which may 
be created by allowing children beer, it will in most cases produce a 
directly injurious effect upon their stomachs, and thus disturb the 
regular nutrition of their bodies. — C.J 

* The importance of not setting the stomach to work during the latter stages of 
digestion, is well put by Dr. Paris, in his able article on Dietetics, in the Cyc. of 
Pract, Med, The maxim should be carefully attended to in feeding children. 



44 MANAGEMENT OF CHILDREN. 

its last meal, of bread steeped in water, &c, as at nine o'clock in the 
morning. A healthy child, who has been in the open air, during the 
greate/part of the day, will be ready for bed shortly after this last 
mentioned supply, and will require nothing more until next morning. 
Similar regimen and hours may be adopted throughout the whole 
period of childhood ; only, as the fourth or fifth year approaches, 
giving, for breakfast and supper, bread and milk, without water, and 
either warm or cold, according to the weather or the child's inclina- 
tion. The supply of food, upon first awaking in the morning, may 
also be gradually discontinued, and breakfast given somewhat 
earlier. 

The foregoing, we conceive, may fairly be offered as a model of a 
suitable diet for children ; but, as Dr. Barlow* judiciously observes, 
" No exclusive system can be right, nor can any precise rule of diet 
be possibly laid down, as this requires to be adapted, in every case, 
to the particular constitution concerned." With the stomach of one 
child, for example, so much milk as we have recommended may 
disagree, and produce acidity, and it may be advisable to substitute 
for it, tea or cocoa ; with another, a meat dinner every day may 
produce plethora, and it may be necessary to alternate it with rice, 
or some other vegetable substance. The constitution of the child, its 
habits of exposure to the air, and its residence in a city or the coun- 
try, must be taken into account ; and something must also be allowed 
for the customs of the community in which it is brought up. 

A judicious parent or physician will recollect all these matters ; 
and while, as we hope, they will be able to derive something like a 
foundation of principles, from our recommendations, they will yet 
recognize the expediency of occasional modifications in matters of 
detail. It is of great importance, that no preconceived system or 
theory, with respect to diet, should be assumed and adhered to, with 
unreflecting obstinacy, as is but too often the case. Thus one class 
of persons, arguing that the growth of a child requires an active 
nutrition, adopt the theory that an excess in the quantity or quality 
of nutritious matter supplied, cannot be committed. Such theorists 
are apt, by cramming and overloading the stomach, to cause the di- 
gestive powers to be impaired to such an extent as will prevent the 
food from being converted into nutriment, and so to produce the 
defect in supply of new material which it is their object to avoid. 
Others, observing a healthy remnant of potato-fed children in an Irish 
cabin, and hearing that the Hindoos live and thrive upon rice, in- 
stantly infer that scanty vegetable food is the true panacea for health 
and longevity ; and accordingly, condemn their offspring or patients 
to the miseries and perils of an insufficient, non-animal diet. Most 
unfounded prejudices are also taken up from ex-parte observations 
as to the wholesomeness or unwholesomeness of individual articles 
of food. Fruits, for instance, are under a general interdict from the 
dietary of children j and the consequence is, that the schoolboy, 

* See his excellent article on Physical Education, in the Cyc. Pract. Med. 



CLEANLINESS. 45 

impelled by his instinct* on the one hand, and restrained by his ma- 
nagers on the other, devours, in secret, and often to his great injury, 
the unripe, ill-cultivated, and pernicious trash of the fruit-stall, instead 
of moderately using, as he should be permitted to do, such whole- 
some, cooling, and antiseptic fruit as the season may afford. Much 
learned trifling has also escaped from writers with respect to the pro- 
priety and necessity of " living naturally, and on such food as is 
presented to us by nature :" and we are often told that children 
should be fed upon bread and milk alone •, because the former is pre- 
pared by the simplest cookery, and the latter in what they call the 
laboratory of nature. Dr. Fordyce, however, has met the question, 
and settled it at once, by declaring that " man has no natural food." 
Let those who may be startled by this proposition call to their recol- 
lection the difference between the milk afforded by a cow kept alive 
upon the weeds and scanty vegetation of a neglected common, and 
one fed upon the riches of a pasture which has experienced the 
transforming power of cultivation ; let them recollect that the wheat, 
of which their so-called natural diet is composed, is itself the result 
of a long course of cultivation, and a full employment of all the re- 
sources of the complicated art of agriculture. " The potato/' says Dr. 
Paris, among many other examples, — " whose introduction has added 
so many millions to our population, derives its origin from a small 
and bitter root which grows wild in Chili, and at Monte Video."t 

The science of Dietetics is, in truth, an uncertain one ; any facts 
that we know respecting it, being liable to be influenced by many 
varying conditions, all of which should be taken into the considera- 
tion of every individual case ; and after all, no theory should be 
permitted the slightest weight in a particular instance in which it 
may be contradicted by experience. If an article of food, in favour 
of whose wholesomeness we have universal testimony, should dis- 
agree with a certain individual, its use with that person must not be 
insisted upon.J 

VIII. CLEANLINESS. 

The importance of the excretion from the skin is universally ac- 
knowledged, and is sufficiently proved by the amount of the daily 
perspiration, which was estimated by Lavoisier and Seguin at an 
average of lib. 14oz. in the adult.§ This discharge being natural 

*'We have the authority of Dr. Paris for the fact, " that artisans and labourers, 
in the confined manufactories of large towns, suffer prodigiously in their health, 
whenever a failure occurs in the crops of common fruits. This fact was remarkably 
striking in the years 1804 and 1805." — Art. Dietetics, in Cyc. Prac. Med. 

f Op. citat. 

X Some very unexpected facts and opinions with regard to the nutritive properties 
of various kinds of food have been lately brought forward in the Report of the Com- 
mission on Gelatin, to the Academy of Sciences of Paris. A translation of this 
remarkable document, in the preparation of which MM. Thenard, Dumas, Flourens, 
Serres, Breschet, and Magendie, were engaged during ten years, will be found in 
the Medical Press, vol. vi., p. 129, and will well repay the trouble of perusal. [Note 
to 4th Edition.] 

§ Lavoisier's Traite Elementaire de Chimie. 



46 MANAGEMENT OF CHILDREN. 

and essential for the preservation of health ; the necessity of remov- 
ing from the body of the child, any obstructions to it which might 
be offered by the adhesion of extraneous matters, must be sufficiently 
obvious. The beneficial action of the physical agents upon the sys- 
tem (of which we shall again speak), as these agents must act i 
through the medium of the skin, leads us to infer a similar necessity. 
The accumulation of impurities upon the surface will also be ob- 
served to produce very distressing excoriations, and even permanent i 
cutaneous diseases, which, when once established, are often with 
difficulty removed. With these considerations in view, we therefore 
feel authorised to advance the dogma, that too much attention cannot : 
be paid to the subject of cleanliness, during both periods of child- I 
hood. 

The infant's body, we have already stated, requires to be carefully 
washed immediately after birth ; and the same operation should be 
performed daily, until the child becomes old enough to attend to its 
own comforts. Washing should at first be performed with warm 
water and a fine sponge, — taking care, in the early periods, that no 
exposure be permitted long enough to produce an impression of cold. 
As the infant grows stronger, and when the weather is warm, we 
may gradually lessen the temperature of the water, until at length it 
may be used nearly quite cold. It is better, however, for the rea- 
sons assigned in p. 32, to be in no hurry about employing a perfectly 
cold bath; and under any circumstauces, we would not recommend 
water to be used without allowing it to remain in the nursery, during 
the night, in order that it may so acquire a slight increase of tempera- 
ture. 3 It is not necessary to use soap, except with parts of the body 
(as the hands and arms) which are particularly exposed to the re- 
ception of impurities ; even with these it should only occasionally be 
employed. Brown soap is better than white, as being less likely to 
cause cracking of the skin, which is often a source of much annoy- 
ance to the child. In all cases, great care should be taken to dry 
the surface well with a soft napkin, especially where there are folds 
of the skin, as between the nates, on the front of the neck, arm-pits, 
&c. A neglect of this precaution will be sure to occasion excoriation, 
and often troublesome sores. To make matters more secure, we 
shall do well in fat children, after carefui drying, to dust the skin, in 
such situations, with some fine dry powder, as hair powder, or starch 

a [Great caution must be observed in the use of a cold bath for a 
young child. If the infant be feeble, or from any cause debilitated, a 
' perfectly cold bath/ or even one < nearly quite cold,' will be liable to 
produce decided injury. In young children, even of a perfectly robust 
constitution, if from any cause the surface of their bodies have become 
chilled, or they are at the time labouring under the effects of fatigue, 
immersing them in cold water is rather a dangerous experiment. Of 
so doubtful propriety, indeed, is the cold bath in cases of children 
generally, and so many circumstances occur to render its use alto- 
gether improper, that we should in all cases, especially during in- 
fancy and early childhood, prefer the tepid or warm bath. — C] 



CLOTHING. 47 

finely levigated and sifted through a muslin bag. This will absorb 
the secretions from the surface, and prevent friction. 

While washing the infant, during the first few days of its life, 
attention must be paid to the condition of the navel-string. The 
linen in which we envelope this part immediately after birth usually 
adheres firmly to it ; and if it remains dry, we need not disturb it, 
but merely raise it gently, so as to admit of the abdomen underneath 
being carefully washed and dried. In ordinary cases, the cord dries 
up and falls off between the sixth and tenth days, ulceration taking 
place at the navel. A small healthy sore remains for a few days 
longer, which will commonly heal up without requiring any inter- 
ference, except the daily application of a piece of dry, old linen. 

The frequency of the discharges from the bowels and bladder of 
an infant, requires us to enforce especial care in changing the napkin 
placed for the reception of those matters — otherwise the skin will 
be injured, and disagreeable excoriations produced. We are to re- 
collect, that, in the natural state, these evacuations are regularly 
periodical ; and an observant nurse will soon discover the periods 
when they are about to take place, and not only anticipate them, 
but teach the child, at a very early age, to give intelligible warning 
of its necessities : the complaint is often made to us of a child's being 
dirty, but it may be relied upon that the fault is almost always with 
the nurse. Indeed, we have no doubt that an orderly education of 
these functions, commenced in the earliest infancy, will be the means 
of establishing a regularity of the bowels which will continue through- 
out the whole of life, — and the more tenaciously, because in such 
training we are not altering or improving nature, but merely work- 
ing in unison with her tendency to periodicity. As the child ad- 
vances, we must continue an unabated attention to cleanliness ; the 
hair must be carefully combed and brushed ; and the ears, eyes, and 
all other openings of passages from the interior of the body, must be 
kept perfectly clean, as well as the skin itself. By adopting such a 
line of conduct, we may count upon certainly preventing most of 
the eruptions, upon the scalp or skin, which have not been directly 
communicated by contagion, and of materially diminishing any ten- 
dency, that may exist, to scrofula, marasmus, or rickets. 

Mere washing would, of course, have little effect, if scrupulous 
exactness was not observed in making frequent changes of the child's 
clothes: an infant, or young child should have a complete change of 
dress every day ; and the linen of elder children should be changed 
very frequently, — so often as to prevent the accumulation of any 
impurity. 

IX. — CLOTHING. 

We have already dwelt, at sufficient length, upon the principles 
which should guide us in the clothing of an infant immediately 
after birth. They are, simply, to preserve a sufficient quantity of 
heat ; and to do so without setting any restrictions upon the free 
movements of all parts of the child's body and limbs ; or irritating 



4g MANAGEMENT OF CHILDREN. 

its tender skin. Although the discoveries of Dr. Edwards, to which 
we have referred at the commencement of this chapter, lead directly 
to the establishment of the first principle now laid down, yet the 
subject is one of such great importance, and so much mystified by the 
phantasies of systematic writers, that we shall make no apology for 
the following long quotation. " It (mortality from cold) is not con- 
fined to children whom the misery of their parents cannot guard 
from the rigour of the weather, but it operates to a great extent, 
without being either perceived or suspected, in families enjoying 
affluence, and in which it is believed that the necessary precautions 
are taken, — because, cold being relative, it is difficult from our own 
feelings to judge of its effects on others, and because it does not always 
manifest itself by determinate and uniform sensations. They do not 
feel the cold, but they have an uneasiness or an indisposition which 
arises from it ; their constitution becomes deteriorated by passing 
through the alternations of health and disease, and they sink under 
the action of an unknown cause. It is the more likely to be unknown, 
because the injurious effects of cold do not always manifest them- 
selves during or immediately after its application. The changes are 
at first insensible ; they increase by the repetition of the impression, 
or by its long duration ; and the constitution is altered, without the 
effect being suspected.""* 

We wish we could, as a commentary upon the foregoing passages, 
adequately depict one of those miserable victims of parental vanity, 
whose appearance in our streets will sometimes, upon a March or 
November day, strike cold into our hearts. The cap and feathers 
set upon, not covering, the child's head, and probably of a colour 
and richness contrasting mournfully with the blue ears, sharpened 
nose, and shrunkened cheeks, in which cold has assumed the features 
of starvation — the short kilt and Highland hose, exposing, between 
them, cracked and quivering knees — altogether require for their de- 
scription more graphic power than we presume to lay claim to. We 
hope, however, that we have said enough to call attention to the ab- 
surdity of the " hardening" system, as it is called, and to show that 
the adoption of a clothing, regulated so as to obviate the rigours of 
our climate, is both demanded by our sensations and sanctioned by 
our knowledge. 

The material of clothing is not, we conceive, of very great conse- 
quence. We are rather inclined to discourage the use of flannel, next 
the skin, in young children ; it is liable to injure the tender and irri- 
table surface, and it is more likely than linen to permit the concealed 
accumulation of dirt. For these reasons, and as children need not be 
exposed to wet, we think flannel next the skin had better be avoided. 
The feet should be protected in winter, by warm stockings, and suf- 
ficiently strong shoes ; and when the weather is particularly cold, 
woollen gaiters should be drawn over the legs, when the child is about 
to be exposed to the air. It has latterly been a good deal the fashion 
to allow children, when a little advanced, to sleep without night- 

* Edwards, op. citat. 



SLEEP. 49 

caps ; and this, we think, may be permitted with advantage, as the 
tendency to morbid excitement of the brain, which is so marked a 
characteristic of childhood, makes it desirable that the circulation 
through that organ should be preserved in as tranquil a state as pos- 
sible ; which can be most effectually done by keeping the head cool. 
The non-confinement of the hair will also promote its growth, and 
in this instance we may very safely leave nature to herself. 

In every article of dress the principle should be carefully followed, 
of placing no constraint upon the motions of any part. For the boy, 
tight-waisted trowsers, or braces ; and for the girl, stays and corsets 
of all kinds, must be forbidden during the whole period of childhood. 
The injuries that may be committed upon the organs in the chest 
and abdomen, by the latter article, are well known to be of the most 
serious nature ; the chest may be completely altered in shape, and the 
lungs diminished in their capacity by a continued pressure so applied ; 
while, at the same time, the stomach and liver are driven from their 
natural position, and made to press upon the other organs of the ab- 
domen. Derangements of the functions of respiration, circulation, and 
digestion, follow as natural consequences, and but too often lead to 
an early grave, or what is perhaps worse, to a life of prolonged deli- 
cacy and ill-health. After all these risks, the object held in view in 
the use of stays is not attainable by their means. By active and con- 
tinued compression upon the lower part of the chest, its shape may 
no doubt be altered, — the ribs may be brought together, so as to 
form a narrower circle, and a shape be produced which, however it 
may be fancied to approach the ideal of beauty, yet bears no resem- 
blance to the human form, either as it comes from the hands of na- 
ture, or exists in the conception of the artist. The only way in which 
we can assist in the production of a really fine figure is, to remove all 
restrictions, and secure, as far as possible, so free an action of the 
muscles as will lead to their perfect development. By such a course, 
also, we shall best promote the acquirement of a good carriage, which 
is infinitely more likely to be the result of a perfect balance of the 
muscles, than of any mechanical support whatsoever. 

If the principle of avoiding constraint were to be held in view, in 
the management of a child's feet, much suffering would be spared in 
after life. Corns and tumours upon the toes are almost always the 
results of tight, or ill-fitting shoes ; and therefore it is highly desirable, 
that we should have these articles so constructed as to protect the 
foot equally, and not injure it by any undue pressure upon particular 
parts. 

x. — SLEEP. 

For several weeks after birth, the infant is disposed to sleep con- 
tinuously, only awakened when pressed by the demands of hunger ; 
and it should certainly be our object not to disturb its repose. As 
its senses become more capable of bearing external impressions ; and 
probably as its sensorium begins to elaborate these latter into ideas, 
the waking interval becomes gradually longer, and, after some time, 
the chief portion of sleep is taken during the night. Throughout the 
5 



I 



■,: 



50 MANAGEMENT OF CHILDREN. 

whole period of childhood, however, more sleep is required than in ; 
adult age ; and up to the third or fourth year, the child will be dis- c 
posed, and ought to be allowed, to sleep for an hour or two during 
the day time. 

In regulating the periods for sleep, as in other matters, we should i 
not forget the periodical plan almost universally adopted by nature ; 
and by a little training, or rather by permitting that plan to operate 3 
without disturbance, the nurse will be saved many a sleepless night. ; 
Matters should be arranged in the nursery, so as that no obstacle 
shall be opposed to the child's sleeping, about the middle of the day, 
an hour or two before its time of dinner; it will thus be again suffi- \ 
ciently tired, in the evening, to ensure its sleeping soundly from seven I 
or eight o'clock, until the following morning. On the other hand, if \ 
we defer its mid-day rest, to a later hour of the day, its night's sleep ; . 
will not commence so early, and (the child being less fatigued) it will 
probably be interrupted before morning. 

A question is often put to a physician : should the child sleep with 
its mother or nurse ? For a month or two after birth, it is unques 
tionably desirable that it should ; for the infant, as we have seen 
possessing a low temperature, and but a small power of generating \ 
heat, requires to be kept warm by contact with another being. In 
support of this conclusion, we may allude to the care which is taken 
by birds and other warm-blooded animals, to preserve heat in their 
young offspring by the almost continual application of their own 
bodies. In our care for the infant, however, we must not forget the 
mother ; and as her health would be likely to suffer from the anxiety 
and disturbance occasioned by being obliged to attend to a child 
during the night, we need not prolong unnecessarily the period of its 
sleeping with her. At the expiration of a month or six weeks, espe- 
cially when the weather is warm, the infant, if healthy, will, with 
due precautions, be able to maintain its own heat, and we may then 
allow it to sleep in a cradle or bed by itself. A sufficiency of bed- 
clothes should be used, and the temperature of the room, during the 
first few months, should not be allowed to fall below 60° F. While 
we are anxious to keep the young being warm, we must be equally 
carefully to permit a free access of pure air, to its mouth, which should 
also be strictly attended to while it sleeps with the mother or nurse. 

In placing the child in a cradle or bed by itself, care should be taken 
to lay it upon its side, as that is the position in which it naturally lies 
upon the arm of the nurse ; and the flowing of saliva and other 
matters from the mouth is thus facilitated. 

There has been, at all times, a considerable expenditure of words, 
and much learned trifling, with regard to the question of the salubrity 
or insalubrity of cradles. It appears to us that their employment, or 
non-employment, is a matter that may very safely be left to the fancy 
or convenience of the parents. A cradle makes a clean, airy, and, 
from the facility of moving it about, a convenient bed, and, as such, 
has advantages over more ponderous pieces of furniture. As to the 
injury likely to be inflicted upon the cerebral system, by rocking, we 
have not the shadow of a proof, that such a species of motion is ever 



SLEEP. 51 

injurious to the brain, either of infants or adults ; if it were so, how- 
would the sensorium of the infant escape the effects of the thousand 
shocks to which it is exposed, and that too in an inverted position, 
before birth ; or, among adults, what sort of brains would the veteran 
sailor possess ? Throughout all our views respecting the management 
of children, we wish to avoid speculating or dogmatising, in the 
absence of any basis of facts ; and to lean to popular opinions, (whose 
antiquity, we are not ashamed to confess, is, in our minds, prima facie 
evidence of their having originated in accurate observation,) rather 
than to affect a pretension to science by abusing, upon a theory, 
practices which possess the sanction of long and general use. We 
cannot, therefore, agree that * rocking must be utterly disallowed," 
or that the reason for its disallowance, viz., that : " Sleep here ensues, 
because the motion promotes a congestive state of the vessels of the 
brain, inducing a degree of vertigo"* — is any thing more than a very 
shadowy hypothesis. 

During the whole of the second period, a child should, decidedly, 
sleep alone, in a bed without any hangings which might impede the 
free access of air, and in a room as larget as can conveniently be pro- 
cured ; not cold, or admitting draughts of wind, but provided with 
the means of free ventilation. As few persons as possible should be 
allowed to sleep in the nursery, and in winter a fire is an essential 
requisite, both for the perservation of a sufficient temperature, which 
should be permitted to fall as little below 60° F. as possible ; and also 
for the promotion of a free circulation of air. 

With respect to early rising, we are ready to admit, to the fullest 
extent, the great advantages, physical and moral, of the habit, but 
still we must protest against a child being, under any circumstances, 
curtailed of its due proportion of sleep. The way to promote early 
rising, safely and usefully, is to train the child to habits of retiring 
early to bed, and then to encourage it to rise immediately upon its 
spontaneous awaking, but by no means to force it from its bed before 
the latter occurrence. No definite rules can or ought to be laid down 
as to the number of hours' sleep to be allowed : one child may require 
more or less than another ; and our only safe guide will be, to train 
it to go to bed shortly after its last meal in the evening, and then 
permit it to sleep, without disturbance, until it awakes, of its own 
accord, upon the following morning. 

The composition of the infant's or child's bed, is a matter of some 
moment — it should be firm and elastic, and of such materials as can 
readily be dried, or altogether changed, when wet. To answer these 

* Cyc. Pract. Med. art. Physical Education. 

f According to Dr. Edwards' view, the advantages of large rooms are not merely 
to be referred to the greater purity of the air : he thinks also that the slight agita- 
tion of the atmosphere, caused by the space being extended, produces such a feeling 
of well-being, that the chest dilates in consequence, and admits a larger proportion 
of air. The agreeable sensation which is experienced on breathing in the country 
is, he says, principally due to that cause. Henke refers short-sightedness to the 
narrow circle of vision rendered customary in confined nurseries. — ddolphe Henke 
Eandbuch der Kinderkrankheiten. Fkt. a M. 1813. 



MANAGEMENT OF CHILDREN. 

cads, a small tick, stuffed with straw, forms the best bed for the infant 
and young child ; the straw should be frequently changed, and the 
tick as often washed, and well exposed to the air. For a more 
advanced child, a hair mattrass answers all purposes. It should be 
exposed daily to a draught of air ; and in summer, placed for an hour 
or two in the sunshine, when that is practicable. 

XI. EXERCISE. 

From the very earliest periods of infancy, some degree of muscular 
motion is necessary for the well-being of the child ; and as Dr. Barlow 
judiciously observes, "it is advisable to suffer them to exercise their 
limbs freely, by laying them frequently on a bed, sofa, or carpet, and 
allowing them to roll and kick at their good pleasure." This, and 
being carried about in the nurse's arms, is all the exercise a mere 
infant requires.* 

In handling and carrying the very young infant, the nurse should 
never forget the delicate and feeble organization of its bones and 
muscles, which are altogether unfit to sustain any weight or pressure. 
During the first four or five months it should never be placed in a 
sitting posture, and when it is carried about, the head should always 
be supported upon the arm or breast of its bearer. In lifting an infant 
also, the arms should never be laid hold of: and care should always 
be taken to make no undue pressure upon the chest, the shape of 
which may, by a neglect of this precaution, be permanently altered. 
It may be" well here to advert to a similar hazard noticed by Dr. 
Barlow, as likely to attend the practice of hoisting, as it is termed ; 
by the hand of the person holding the child being placed with the 
thumb and fingers on each side of the sternum. Hoisting should not 
be practiced with an infant under six or seven months old ; but even 
at that age, it appears to us extremely probable that some impression 
may be made upon its chest in the manner referred to, and we should 
therefore caution the nurse against allowing it to be so grasped. The 
act of hoisting, itself, appears to be always attended with pleasure to 
a healthy child ; probably in consequence of that sense of well-being 
which we have already noticed as being produced by agitation of the 
atmosphere ; and provided it be practised with care, that no risk of a 
fall shall be incurred, and the child be old enough to bear it, it need 
not be interdicted. 

With respect to the period of the child's walking, we conceive that 
its commencement should be left entirely to nature. Spontaneous 
efforts will never be made to an extent likely to produce injury ; but 
go-carts, &c, should be banished from the nursery, as by such con- 
trivances, the child will be supported, and induced, prematurely, to 
walk, before its limbs have acquired sufficient firmness to enable them 
to support the weight of the body. By these attempts at anticipating 

* Nurses are in the habit of rubbing the infant's body gently with their hand, 
during the time of dressing. This friction appears to be agreeable to the child, and 
is probably useful by stimulating the surface, and promoting the cutaneous circula- 
tion. It may be considered as a species of exercise. 



EXERCISE. 53 

the child's strength, its legs may be made crooked, or a still worse 
effect may be produced in female children by causing distortion of 
the bones of the pelvis, the evil consequences of which may be first 
discovered when the child herself is about to become a mother : such 
results, however, are scarcely to be dreaded when the commencement 
of walking is a voluntary act. As soon as the child is able to support 
itself in a sitting posture, that is from the eighth to the twelfth month, 
it should be occasionally placed upon a carpet, with some playthings 
spread about it. Towards these it will soon endeavour to creep, and 
after some time, when its locomotive muscles have acquired greater 
strength, attempts will be made to assume the erect posture, and ulti- 
mately to walk alone. 

In early childhood, the taking of exercise may in like manner be 
left altogether to nature; all we have to do is to provide opportunity, 
by allowing the free and unrestrained use of a garden or field, in fine 
weather ; or of a large nursery at other times. The active and rest- 
less spirits of the child will then prompt it to do all that is required 
for its health, and its own sense of fatigue will be the best monitor 
as to the proper duration of its exertions. 

When the child grows into the boy or girl, more consideration 
becomes due to the management of its muscular system, as the neces- 
sity for dedicating definite portions of time to mental education then, 
first, arises. It then becomes an object to economise the hours of 
exercise, and for this purpose the gymnasium and dancing-school 
are sought by parents, and recommended by physicians. The latter 
is generally considered rather as a place for acquiring an accomplish- 
ment than for exercise ; but under a judicious master, who avoids 
constrained positions and restrictive machinery, dancing may do ex- 
cellent service, by giving vent to the buoyant spirits of youth, and 
exercising almost all the muscles. The gymnasium has certainly 
been an improvement in modern education, but it, too, has its evils 
and hazards. In it also a skilful teacher is required, whose know- 
ledge of muscular anatomy will enable him to contrive means of 
generally exercising the frame, and whose judgment will constantly 
interfere to prevent the youth from being carried on by spirit and 
emulation to an overtaxing of his own powers. When practised to 
too great an extent, gymnastic exercises certainly stop the growth,* 
by directing all the energy of the individual towards a development 
of the muscular system : if improperly directed, they may also occa- 
sion ruptures, and injuries to the joints ; but under a skilful teacher, 
such abuses may be certainly and safely prevented. Neither gym- 
nastics nor dancing ought, however, to supersede the daily play in 
the green fields, and both parents and children are fortunate, when 

* Any person who recollects the stunted stature of a boy, servant in a gymnasium 
in this city, will admit the truth of the above statement. We are happy in being 
able to corroborate our, somewhat heterodox, notions, respecting the abuse of gym- 
nastic exercises, by the authority of Dr. James Johnson. He, also, very correctly, 
points out their tendency to call into activity diseases of the heart and great vessels, 
in young individuals previously predisposed to those affections. — Vide Economy 
of Health. Lond. 1837. 
5* 



5{ MANAGEMENT OF CHILDREN. 

not called upon by circumstances to sacrifice this, the most healthful 
and most invigorating of exercises. 

Our plan, (restricting our observations to the management of child- 
hood,) does not warrant us in considering at any greater length the 
exercises of youth, — a full view of the merits and peculiarities 
of the different kinds of which belonging more to the province of the 
physiologist, than of the child's physician. With respect to the 
quantity of exercise to be permitted to the child, we can give no rules 
more definite, than to allow the dictates of nature to be followed - 
when fatigue is experienced and rest called for, and to adopt the views j 
already put forward as to the proper periods for sleep and food ; by ;, 
carefully attending to these latter, regular interruptions to play or 
continuance in the open air, will, of course, be provided for, and that 
to an extent adequate to the wants of the individual.* 

XII. MEDICINE. 

There is no subject connected with the management of children, 
in which such fatal errors have prevailed, as the treatment of their 
bowels; and unfortunately, the influence of certain medical theories 
has, of late years, tended rather to the increase than diminution of 
those mistakes. The importance which has, in many respects very 
justly, been attached to the condition of the digestive system in 
disease, has attracted much attention to its state in health. Unhap- 
pily, however, the great majority of persons fall into the grievous 
fallacy of supposing that what is useful as a remedy, must also be 
useful as a preventive ; and as the multitude have, in the case of 
the system in question, but one idea, cognate with either remedy or 
preventive, viz., the idea of purging, the propriety of adopting a 
regular system of purgation with healthy children, has been admitted 
almost without question. There cannot, however, be a more danger- 

* It is much to be desired that public gardens should be established in our large 
towns, to which the inhabitants, of all classes, and their children, could have access. 
They should be planted with shrubs and trees, so as to afford moderate shelter, — - 
and be provided with a large shed, in which refuge might be taken from the vicissi- 
tudes of our variable climate. Most, large, continental towns have a provision of 
this kind, as well as numerous private gardens, tow T hichthe poorest can resort at no 
greater expense than the price of a cup of coffee. We know that it will be objected, 
that, in our country, such places would become scenes of drunkenness acd riot; but 
we are sanguine enough to hope, that the opportunity of enjoying temperate amuse- 
ments in the presence of their fellow-citizens, of abetter rank, would be appreciated 
by our artisans, and ultimately tend to restrain their ferocity, and elevate them in 
their own opinions. The lower classes, of these countries, are too much thrown 
upon the one brutal indulgence of drinking; and it is an absurdity to suppose that 
the strictest revenue laws will have any effect, except to aggravate the evil. Make 
spirits dearer, and the labourer will certainly diminish his allowance of food and 
clothing to procure the only means within his reach, of relieving his mind from the 
pressure of toil and want. Give him an opportunity of being amused, w 7 hen his 
day's labour is ended, with music ; and of enjoying the pleasures of a public garden, 
in the presence of his superiors, and we hope, (perhaps too sanguinely,) that he will 
be gradually led to lessen his allowance of spirits, in order to enable him to procure 
dress sufficiently decent to admit of his partaking in these amusements, without a 
sense of degradation. 



MEDICINE. 55 

cms absurdity than such a system ; and in proof of our opinion, we 
shall ask a single question, and bring forward a single fact. What 
is the mode of action, and effect of every aperient drug in the phar- 
macopoeia ? — Is it not irritation, direct or indirect, of the intestinal 
mucous membrane, in a greater or lesser degree ; and does it not pro- 
duce, as a necessary effect, in every instance, a larger or smaller 
quantity of increased secretion ? So much for our question. We 
presume that, except among the disciples of St. John Long, no person 
will be found to maintain that irritation producing increase of secre- 
tion, can ever be necessary in the healthy body. With respect to 
our fact — let any person with regular, or moderately regular bowels, 
take an aperient, and he will certainly find that after its immediate 
effects have passed away, a state of costiveness will be the conse- 
quence. All the operations of nature are characterised by a tendency 
to periodicity, and whenever the regular periodical action, which she 
has ordained for the digestive canal, is interrupted by the production 
of evacuations, at irregular periods, she will require some time to 
enable her to recur to the simplicity of her original design. This is 
the true theory of the constipating after-effect of purgatives. 

We wish it to be distinctly understood, that what we are now 
advancing has no reference to the use of purgatives in disease, but 
solely to their abuse during health ; and we are the more particular 
in endeavouring to convey our own views upon the subject, because 
we know that the impropriety of a needless resort to medicines of 
this kind, is not sufficiently thought of by medical men. We have, 
indeed, too often had occasion to lament over the display of drugs 
upon the mantel-piece of even a medical man's nursery, not to feel 
special interest in this matter. The least judicious would surely 
grieve, did he see an ointment of cantharides rubbed upon a healthy 
skin with no other apparent intention than that it might be followed 
by a healing salve ; yet, what, less absurd, is portended by the accu- 
mulation, in such a situation as we have alluded to, of packets of 
aperient draughts, bundles of restraining powders, and bottles of car- 
minative mixture — all designed for the same unlucky children. This 
is no imaginary description ; we have, but too often, seen its original; 
yet, better and more merciful would it be, towards many of the 
victims, to destroy them in the birth, than, by such a course, to pro- 
vide for them the enduring, moral and physical, miseries of an irrita- 
ble mucous membrane. 

The bowels of a healthy infant, after the meconium has passed 
away, should be opened from two to four times in the twenty-four 
hours. The discharge should be fluid, of a lightish-yellow colour, free 
from fetid or acid smell, and destitute of lumps, or white curdy mat- 
ter: it should pass without pain, or any considerable quantity of 
wind. As long as these conditions exist, there is no occasion for 
medicine; should they be, materially, deviated from, a state of dis- 
ease must be present, and will be indicated by other symptoms, the 
nature and treatment of which shall be considered in the proper 
place. The infant may, however, labour under a degree of costive- 
ness which can scarcely be called disease, and may yet require 



5 g MANAGEMENT OF CHILDREN. 

medical interference. Having less than two stools, for example, in 
the twenty-four hours, calls for an aperient; and so also does a 
lumpy, or partially solid, condition of the discharge. The medicine, 
in such cases, should be of the mildest nature. For an infant, from 
half a drachm to a drachm of fresh castor oil, will generally answer 
every purpose ; or a dessert-spoonful of a mixture, formed of a couple 
of drachms of manna dissolved in an ounce of fennel or carraway 
water, may be given, and repeated every hour until the bowels are 
opened. These are probably the only safe nursery medicines. 
Calomel, which is but too commonly the first article in the list, should 
be banished from it altogether, and never given for the mere removal 
of, what we may perhaps call, healthy costiveness. Its use seldom 
fails to produce motions of a green colour, mixed with gelatinous 
mucus ; thereby showing that it is likely to do much more than we 
want, when our object is merely to empty the bowels of their con- 
tents. 

During childhood, the bowels should be regularly freed once or 
twice a day (some difference existing in individuals as to the precise 
number of their periodical motions). The discharge should be rather 
of a darker yellow than in the infant, and more solid, but less so than 
in the adult ; it should have a feculent smell, and be free from mucus, 
or lumps of indigested matter. When a healthy child has been 
treated upon the principles which we have indicated, — under the 
heads of food, exercise, and cleanliness, — it will seldom require any 
purgative medicine ; but occasionally, from some error of diet, or 
other accidental circumstance, costiveness will occur, and we must 
then be prepared to recommend a mild aperient. A couple of 
drachms of castor oil will usually answer very well ; or, if that should 
disagree with the stomach, a table-spoonful of the mixture directed 
below, may be given every second or third hour, until it operates.* 
In childhood, as in infancy, the domestic use of calomel cannot be 
too strongly interdicted. 



XIII. EIGHT. 

The influence of this physical agent in the vegetable kingdom, is 
known to every one who has observed the bleached appearance of 
a plant growing in the dark, or has noticed the efforts made by 
flowers, placed near a window, to turn towards the light, even 
though they may not be exposed to the direct action of the solar 
rays. It can scarcely be doubted that similar effects are produced 
upon animals, and Dr. Edwards has made some ingenious experi- 
ments to show the influence of light upon their development. In 
the course of his researches, he found that those imperfect animals 



R. Infusi Sennee Compositi, ^iv. 
Aquse Carui, ^ii. 
Tartratis Potassae, Jii. 
Mannae Optionee, 5i M.. 

Fiat mistura. 



AIR — HEAT. 57 

which naturally change their form, as tadpoles, were prevented from 
doing so by the withdrawal of light, In man it is not easy to 
obtain any information as to the specific effect of light unaided by 
air and heat ; but from the facts just alluded to, we are warranted 
in inferring analogically that light must materially influence develop- 
ment of form. The infant, therefore, as soon as its eyes lose their 
extreme sensibility, should be freely exposed to light. The nursery 
should never be darkened during the day ; and at night, it is better 
that the shutters should be left unclosed, and no window- curtains 
used. 

xrv. — AIR. 

We hope the stress which we have laid upon the propriety of 
keeping up a due degree of warmth in the nursery, will not be inter- 
preted as warranting any measure likely to interfere with a free 
access of air. Both objects are perfectly compatible. The purity of 
the air in which the child resides and sleeps should be secured, by 
providing means of ventilation, in a sufficient number of windows, 
and a chimney, which latter is absolutely essential to the establish- 
ment of a current of air ; and also by restricting the number of indi- 
viduals residing in the apartment, within the narrowest possible 
limits. It has been already stated, that a certain agitation in the 
atmosphere is healthful j and, therefore, the nursery should be as 
large as possible, in order to favour motion of the air contained within 
it.* But our attentions with regard to air, should not be confined to 
the nursery; the vivifying influence which it has been shown to 
produce upon the system, by contact with the surface of the body, 
furnishes us with an explanation of the advantageous results, which 
experience shows to be derivable from an exposure of the child to 
the open air as freely as possible, consistently with an observance of 
the principles already inculcated under other heads. It is this vivify- 
ing influence which renders the play in the open fields so much 
more useful than the most carefully directed exercises of the gym- 
nasium. 

XV. HEAT. 

We have already incidentally said so much upon this subject, that 
anything further would be merely repetition. We may, however, 
take the opportunity of controverting a very common fallacy, viz., 
that exposure to heat renders the body more susceptible of the ill 
effects of cold. Dr. Edwards found, that "in exposing animals to 
successive applications of cold, their temperature will fall the more 
slowly, the longer they shall have been subjected to the influence of 
warmth. Hence, that those who are liable to frequent exposure to 
severe cold, are rendered more capable of supporting it, by subject- 

* Mr. Carmichael, in his admirable lectures on Scrofula, published in the 3d 
Vol. of the Medical Press, deprecates the practice, common in these countries, of 
placing nurseries in the attic stories of houses, where they must of necessity be re- 
cipients of all the foul aif generated in the apartments beneath. The caution is 
well worthy of being attended to. [Note to 3d Edition.] 



5S MENTAL AND MORAL; EDUCATION. 

ing themselves, in the intervals, to a high temperature." We find, 
in point of fact, that the Russians, and other northern nations, pre- 
serve, by means of stoves, and double doors and windows, a very 
high temperature in their dwellings during winter, and yet leave 
them with impunity to pursue their occupations in the open air.* 
This should make us hesitate in denying access to a fire, to a cold 
and shivering child, under the idea that we shall render him, by the 
prohibition, hardier, and less likely in future to suffer from cold. 



CHAPTER III. 

MENTAL AND MORAL EDUCATION. 

The connexion between mental and moral education, and the phy- 
sical management of children, is so close, and the action and reaction 
of the one upon the other so constant and influential, that an essay 
upon the latter would be incomplete, indeed, almost useless, without 
some notice of the former subject. In turning our attention, how- 
ever, to this most important of human concerns, we feel considerable 
embarrassment, both from the difficulties incidental to the subject, 
and from the narrowness of the limits within which the nature of Our 
present plan obliges us to confine our observations ;_ at the utmost 
we can deal but in generalities, and even with these only in the 
briefest manner. 

In the foregoing chapter we commenced our consideration of phy- 
sical education, by supposing an infant to be placed in our hands 
immediately upon its entrance into the world. We found it naked 
and helpless, in fact a mere vegetative beingjwith its organs of nu- 
tritive life fitted, and ready to act, but altogether dependent upon 
the care of others for such a supply of material for these organs to 
work upon as was absolutely necessary to preserve its extstence. 
Pursuing the subject, we endeavoured to investigate the nature of 
the various physical wants of the child, and to point out the princi- 
ples which should guide us in administering to and supplying them. 
We are now in a precisely similar position with regard to the moral and 
intellectual system of the young being — it is placed in our hands 
fresh from nature, and we are called upon to make a like investiga- 
tion into the wants of the system in question, and to consider, in like 
manner, the principles upon which we can most safely and prudently 
obviate or regulate them. 

The progressive development of the various intellectual powers in 
the child has been already alluded to in the first chapter, and to the 
course of this development we must Look for our only natural guide 

* The common winter temperature of houses in St. Petersburg, is 64° F. ; while, 
out of doors, it is frequently so low as 20°. — Dr. GranvilWs Travels. 



MENTAL EDUCATION. 59 

in all attempts to educate these powers. The infant at birth, we have 
seen, (p. 21,) possesses little capability of perception; some of its 
senses are still imperfect, and all are, from want of training, unfitted 
to convey correct information to the mind ; the memory is as yet 
unfurnished with facts ; and the whole system is, as it were, a ma- 
chine in some degree ready for work, but from which the moving 
power is still withheld. Soon, however, the process of learning com- 
mences ; the senses first receive a knowledge of the agents which 
act specifically upon them ; the eye becomes acquainted with light, 
and afterwards notices objects which are presented to it; the ear is 
affected in like manner with regard to sound ; the skin, the seat of 
the sense of touch, becomes gradually instructed in the more obvious 
properties of matter. Subsequently the infants learns to compare 
the impressions made upon the different senses, and to derive infer- 
ences from the comparison. A familiar example will best illustrate 
this dawning of intelligence. Thus, the mother's nipple is soon re- 
cognised by the sense of sight, and probably the first item of know- 
ledge laid up in the memory is the fact that this is the source from 
whence nourishment is derived. A careful observation of the young 
infant will, however, soon teach us that although it very early per- 
ceives the nipple, and is not ignorant of its use, still it has at first no 
knowledge of its position in relation to that of its own body. Such 
knowledge is the result of a comparison between the impressions 
made upon two senses, and it is not until a later period that the 
information conveyed by the sight is corrected by the touch, so far 
as to enable the mouth or hands to be directed with certainty towards 
the object in question. After a short period, the power of perceiving 
external objects is so far educated, and the memory so well stored 
with facts, the result of observations, that the infant can determine 
the differences between persons, and becomes capable of recognizing 
its mother or nurse. 

All this is really mental education, and that too of the most im- 
portant kind ; for what a small proportion does the learning of the 
schools bear to the knowledge of external agents, and of our own 
.powers and relations, which we must acquire during the period of 
childhood, and without which we should be incapable of supporting 
our existence. What countless observations must be made before we 
ascertain our ability to speak or walk, and what a wondrous mass of 
facts must be learned before we understand in the most general way 
the difference between animate and inanimate bodies ; between the 
firm and resisting land, and the yielding and unstable water. 

We cannot, however, directly aid in the communication of such 
knowledge ; the demands of the senses for their proper excitements 
will not fail to force its acquisition upon the young being ; and we 
refer to it, here, only to show that the young child who is permitted 
to use its eyes and ears, is always busily employed in learning, and 
that the hours of play are not to be considered as periods of intel- 
lectual idleness. 

At what time the business of formally instructing the intellect 
should be commenced, becomes an interesting question, and one 



60 



MENTAL AND MORAL EDUCATION. 



upon which much difference of opinion exists ; if we begin too early, 
we shall certainly injure the health; and if we delay too long, we 
shall often experience much difficulty in restraining the habits of 
bodily activity, (which in such cases will generally be acquired,) 
within limits favourable to the necessary exertion of the mental 
powers. In this, as in most other matters, we shall probably find our 
best guide, if we carefully observe the plans of nature. She seldom 
fails to implant in the child a most restless and prying curiosity, 
which is in reality the appetite for knowledge, and should never be 
denied its gratification. Books and pictures never fail to attract the 
attention of very young children ; and allowing them to apply it, at 
their own pleasure, to these, and especially to the latter, is doing for 
the mind precisely what we do for the body when we place it in the 
garden or field — it is giving it an opportunity of taking wholesome 
exercise, which will be desisted from upon the first approach of 
fatigue. In the one case the child will, itself, learn to walk and run 
with firmness ; and as its muscles and bones become stronger, it will 
usually show an inclination to practise the more artificial exercises 
of riding and swimming. In the other case, an acquaintance will be 
imperceptibly established with the forms of letters, and of animals 
and other external objects ; and the uses of the one being gradually 
learned, and a curiosity respecting the others being excited, a growing 
desire for information will lead the child to devote more and more 
time to its acquirement, until at length we shall find it no difficult 
matter to include, among our periodical arrangements, an allotment 
of a short portion of each day for the purposes of instruction. The 
precise age for adopting this latter arrangement cannot be exactly 
defined — it must differ a little according to the strength of the child, 
but we conceive it should not be before the sixth year. The space 
of time to be allotted for instruction is also a matter of moment ; it 
should never be long enough to produce fatigue, and we think 
should not exceed two hours daily during any part of the period of 
childhood. 

When considering, in the last chapter, the subject of physical 
education, we avoided entering into a detailed examination of the 
various exercises suited to the development of the muscular system 
in youth, considering such a detail as lying rather within the province 
of the general physiologist, than of the child's physician. In like 
manner, we now conceive that a special consideration of the subjects 
of mental education would be encroaching upon the domain of the 
moral philosopher; the objects, however, of this process, and the mode 
of attaining them, may fairly engage a small share of our attention, 
from their intimate connection with the bodily health of the child. 

In the first place, then, we cannot but think that a grand mistake 
is very generally made with respect to the proper object of education, 
which is commonly supposed to be the storing of the memory with 
a quantity of verbal knowledge, with a mere crowd of words, often 
to the exclusion of the ideas which those words are designed to con- 
vey. Thus, very young children are mechanically taught lengthy 
rhymes, or verbose catechisms of geography and history, and their 



MENTAL EDUCATION. 61 

repetition of these by rote is looked upon and exhibited by their 
parents as a pregnant proof of a precocious understanding. All the 
time, however, the poor child comprehends nothing of what it has 
been repeating, and its memory, which, it must be recollected, has 
abundant employment during the first years of childhood, in storing 
up the facts derived from impressions upon the senses, has been, 
not wholesomely exercised, but injuriously fatigued by the exertion. 
We were much struck with the monstrous absurdity of this wordy 
instruction, upon observing its effects in some of the parochial schools 
of this country. Many of those institutions are under the patronage 
of a society whose inspectors annually visit them, and examine the 
pupils. The examination chiefly consists in ascertaining how much 
of the Scripture can be repeated by rote, and the rule is, that unless 
a certain number of children be produced, each capable of reciting, 
at least, four chapters of the New Testament, no remuneration is to 
be given to the master. The result of this system, as we have re- 
peatedly found from personal investigation, is, that while so much as 
an entire epistle will, in some instances, be correctly repeated, the 
sense of a single paragraph will often not be comprehended by the 
child. In the course of. a very extended visitation of these schools, 
we have been repeatedly told by the masters that their own time, and 
that of the pupils, was so completely occupied with the committing 
of mere words to memory, that it became utterly impossible to pay 
any attention to their meaning. 

Now, if we reflect for a moment upon the exercise to which the 
memory of the young child is subjected in laying up a knowledge of 
its relations to the things and persons which surround it ; and if we 
recollect the mental exertion it undergoes in obtaining a practical 
acquaintance with its obligations to society, and receiving instruction 
as to its expectations of the future, we must surely pause before 
tasking it with the remembrance of words of which it is unable to 
comprehend the value. 

The acquisition of verbal knowledge, or indeed of almost any 
knowledge which can be conveyed by words, we do not look upon 
as a legitimate object of early education. The effort should rather 
be made to instruct the mind in the performance of its functions ; and 
in choosing a mode of doing this, due regard must be had to the order 
in which the mental powers are developed. The perceptive facul- 
ties, for example, coming earliest into play, the instructor's object 
should at first be to impress upon the child a knowledge of the pro- 
perties and relations of matter in its various forms ; and in doing 
this, he should, as far as possible, train the mind to habits of correct 
observation. Materials for thought will in this way be stored for 
future use, and at the same time an orderly and accurate habit of 
observing will be impressed upon the mind. As the reasoning powers 
begin to be developed, these, too, should be trained into their proper 
action. Comparisons should be instituted between things which have 
been already the subjects of separate observations. General laws 
may be explained, and the child may be encouraged to investigate 
the causes of various natural operations which it has previously ob- 
6 



MENTAL \M> MORAL EDUCATION. 

I - 

, ,1 \11 this, however, must be done gradually,and with caution, 
mind of the child, like its body, is incapable of great or long- 

r«ed exertion, and to subject it to such before its powers are 
developed, would be to urge it into premature decay. "We must 

» to borrow the words of an ingenious writer, "attempt to iorce 
Iheir inteilectoal growth, must not feed them with meat, until they 
have teeth to masticate it. There is a great deal which they ought 
to learn, can Learn, and must learn, before they can or ought to under- 
hand n."- _ ' ' . 
So much for intellectual education : it must not be forgotten that 
our consideration of it has been restricted to the first eight years oi 
life, and during that period it should scarcely, in our opinion, be made 
a matter of formal business, but the foundation of it should rather be 
laid by such playful exercise of the faculties as we have sketched. A^ 
more "important subject, however, is what we have designated as 
vwml education, this commences at the earliest period of infancy, 
and, we almost believe, is finished, for good or for evil, before the 
individual passes the epoch of childhood. In moral qualities the child 
is indeed father to the man ; and the education of these requires the 
most anxious attention, even during the earliest periods of infancy. 

one who is familiar with the habits of infants can avoid 
observing, that from the moment of birth they display obvious marks 
of being endowed with active passions and affections, and that, too, 
in proportions varying much in different individuals. Anger is per- 
haps the first of these which is displayed to our notice, but shame 
and jealousy soon make their appearance, and also some, of a more 
amiable character, as compassion and brotherly affection. Now, we 
must recollect that these emotions, and all the other elements of our 
moral constitution, are originally designed, and implanted in us, for 
good. " It is very true," says Dr. Chalmers,! " that the anger, and 
the shame, and the emulation, and the parental affection, and the com- 
passion, and the love of reputation, and the sense of property, and the 
conscience of moral sense, are so many forces of a mechanism, which, 
if not thus furnished, and that too within certain proportions, would 
run into a disorder that might have proved destructive both of the 
individual and of the species.' 7 We shall give an example of our 
meaning, and again in the words of the pious and eloquent writer 
just quoted. " The more patent view of anger is, that it is an instru- 
ment of defence against the aggressions of violence or injustice, and 
by which they are kept in check from desolating, as they otherwise 
would, the face of society."{ In this way the passion of anger, (which 
we take merely as an example,) is not to be considered as in itself evil, 
which is too often the view taken by superficial observers, but it is to 
be looked upon as a necessary constituent of our moral system, 
without which we should be unable to feel a suitable abhorrence of 
sin or of injustice, such as in the present state of man is absolutely 
necessary for the holding together of society. It is only the improper 

♦j'The Doctor," generally (we believe) attributed to the pen of Southey. 
t Bndgewater Treatise, vol. i. , p. 196. % Op. citat. p. 208. 



MORAL EDUCATION. 63 

direction of anger, or its indulgence unrestrained by the other elements 
of our moral constitution, which is productive of evil. In like manner, 
all the other passions and affections are designed for good : and we 
conceive, therefore, that our object in morally educating a child, 
should be, not to obliterate those forces of his moral mechanism, but 
to guide them into a system of harmonious operation with each other. 
Now, how is this most likely to be accomplished ? Is it not by cul- 
tivating those affections which are more obviously good, and by their 
influence regulating the violence of others, whose unrestrained indul- 
gence would certainly lead to evil ? — Thus, the anger even of a 
very young infant will be hest restrained, not by a display of anger 
upon the part of its parent, but by a steady exhibition of parental 
affection, and by showing it a practical example of calmness. Causes 
likely to excite irritability should also be carefully removed from the 
infant, as a habit of indulgence in anger will readily be acquired before 
the counteracting affections can be correspondingly excited. 

As the child advances in age, new passions and affections call daily 
for our notice ; and as its mental education simultaneously progresses, 
and it is constantly acquiring an increased knowledge of external 
objects, we are furnished by this progress and knowledge with addi- 
tional and powerful instruments for influencing its moral nature. He 
displays, indeed, but a small acquaintance with the human heart, who 
hopes by an apothegm to extinguish the passion of jealousy, or to 
repress the cravings of ambition by a dry statement of the unques- 
tionable truth ; that all is vanity. But, still the natural feeling of 
emulation, which is the commencement of jealousy, can be restrained 
within just and wholesome limits, by calling into play the family 
affection, and the compassion, which are equally original elements 
of the moral constitution ; and the love of reputation maybe prevented 
from growing into a dangerous ambition by encouraging, along with 
the affections just mentioned, a development of the conscience or 
moral sense, and of the sense of property, both of which we conceive 
to be inherent in our nature. The child may in this way be practically 
shown, that while a generous rivalry in its sports and lessons is not 
forbidden, still that benevolence, and natural affection for its brothers 
and playmates teach it to stop short, in every instance, of carrying 
this so far as to wound the persons or feelings of others ; and, again, 
that while it may be lawfully anxious to obtain credit and praise from 
its teachers, still that its sense of property forbids it to seek for either 
by making an unpermitted use of the labour of others,and its conscience 
peremptorily interdicts any advantage which might be attained by a 
departure from truth. In this way we avoid overtaxing nature ; — 
we do not vainly denounce, or attempt to obliterate, forces which are 
as much part of our moral frame, as hunger is of our physical ; — we 
do not tell the hungry man he shall not eat, because gluttony is a vice, 
but we furnish him with a guide as to the quantity and quality of food 
which is wholesome and necessary. Above all the restraining prin- 
ciples (if one may be preferred to another), we would be inclined to 
endeavour with most care to bring into activity the sense of property ; 
and conscience, or the moral sense, as Dr. Chalmers terms it. Upon 



6 ^ MENTAL AND MORAL EDUCATION. 

these the well-being of society mainly depends ; if not encouraged in 
early childhood, they are of all others the most likely to remain 
dormant j but if once well developed in the child, a long course of 
vice will scarcely effect their overthrow. 

The progress of mental knowledge may be brought into useful 
operation in this part of our work, if we direct the growing faculties 
of the child to a contemplation of such portions of the general plan of 
nature as may be within its comprehension. Thus, admiration of the 
skill of Providence may, at a very early age, be excited by calling 
attention to the more obvious adaptations of means to ends, as in the 
forms of animals, in the benefits conferred by the mode of distribution 
of water over the earth, and in a thousand other examples which will 
constantly suggest themselves, and a perception of beauty can be 
called up in a very young mind, by the colours and fragrance of 
flowers, and the influence of music. From all these the watchful 
parent can derive practical lessons of humility and love, which 
would be sought, in vain, in the maxims of a dry morality.* 

* We were sorry to observe that Dr. James Johnson, in his able and justly popu- 
lar work upon the " Economy of Health," has, in his desire to prevent the abuse 
of music, been led away from a fair appreciation of its use as an agent in moral 
education. We would heartily join with him in discountenancing the system 
which leads to a periling of the health of our young ladies for the purpose of con- 
verting them into opera singers ; but this is altogether different from the wholesome 
use of music as a language proper forgiving expression to the milder, and for taming 
the fiercer qualities of our nature — as the gentlest, and yet most enduring of our 
social bonds. So far, perhaps, the advantages of music are generally appreciated, 
at least in the case of the upper classes of society ; but its suitableness as an agent 
for the moral education of the poor, is, we regret to say, totally overlooked in this 
country, and yet the education which the poor man chiefly requires is to have his 
fierceness tamed, and his gentler affections called into play — to be bound to his 
fellow-man by partaking in a common source of enjoyment, rather than to be divided 
from him by that jealousy which must exist between the poor and the rich, when- 
ever the intellects of the former are educated without simultaneous attention to 
their physical comforts, and simultaneous instruction of their moral nature. The 
poor man, as well as the rich, requires recreation after labour, a fact which appears 
to be totally forgotten by our philanthropists, who, while they enjoy the indulgences 
of their comfortable homes, can see no excuse for the intemperance of the hard- 
worked labourer, or artisan ; whiskey, however, is merely resorted to as the only 
attainable means of relieving the exhaustion of protracted toil, and the first effec- 
tual temperance institution will be the placing within reach of the poor, some tran- 
quillizing and social amusement. Those who have mixed in the society of the 
lower class of beer-houses and gardens, in the North of Germany, will not deny 
that music may be made to answer this end. 

Many will admit the justice of the foregoing views, but will ask, how are they 
to be acted upon ? We answer — let those who have the direction of the great ex- 
periments of education, at present in progress, abandon polemical controversies, and 
seek for guidance by examining the merits and demerits of systems which have 
been tried in other countries. If they inquire into the state of the Prussian and 
Saxon schools, and their enviable results in the happy condition of the people of 
those nations, they will, or we are much mistaken, change their course. They 
will probably be content with training the minds of the children to work without 
burdening those who are to live by manual labour with much intellectual know- 
ledge : they will especially try to regulate the moral nature of their pupils, and they 
. will, we hope, make musical instruction, as it is in Saxony and Prussia, a part of 
the system of every school. [Note to 2d Edition.] 

We are rejoiced to find that the views put forward in the foregoing Note are be- 



MORAL EDUCATION. 65 

To work out in practice the principles we have attempted to lay- 
down, we are well aware, would require qualifications on the part of 
the parent or teacher, of no ordinary kind ; and will, no doubt, in too 
many cases be impossible of accomplishment : but the nearer we can 
approach to them, the more likely are we to produce the mens sana, 
which we feel confident is fully as certain of producing, as of inhabit- 
ing, the corpus sanum. 

Our limits forbid us to enter at greater length into this most inter- 
esting subject ; but one word we must add, to prevent misconception. 
We have not yet spoken of religious instruction as a part of moral 
education, because we have been considering the management of the 
moral faculties as they exist in the natural man : we are deeply con- 
vinced, however, of its necessity and importance ; and we are firmly 
of opinion, that in no way can we promote the interests of an indi- 
vidual, both as regards himself and hisrelations with society, so effec- 
tually, as by encouraging in him early habits of religious observ- 
ances ; in no way can we so surely call forth and strengthen his 
best affections, as by early setting before his view the living truths of 
revelation. 

As general conclusions from the views we have put forward, we 
would say, that during childhood {i. e., until the eighth year) educa- 
tion should have for its main object the cultivation of the moral 
qualities ; and that, during the greater portion of the same period, 
the intellect will be pretty fully occupied in obtaining such most 
necessary information, as can be acquired by the use of the senses 
without much formal assistance, and therefore that schooling, pro- 
perly so called, should not be commenced, at the very earliest, before 
the termination of the sixth year. Until then, the confinement of a 
school is injurious to the bodily health, and not required for the men- 
tal improvement of the child. In coming to these conclusions, we 
may appear to undervalue those useful inventions of late years, — 
infant schools. We conceive, however, that they are designed for a 
specific purpose, which, when well regulated, they effect usefully — 
viz., to take charge of the children of the poor in large cities, when 
their parents are engaged in daily labour, and unable to attend to 
their wants. In this view, the value of these institutions is inestima- 
ble ; but still they are but the substitution of a lesser for a greater 
evil : all the ties of social affection, of well-regulated obedience, and 
of mutual co-operation, which constitute the bonds of society, are 
learned by the infant in the domestic circle, andean be learned nowhere 
else. If we can leave it, therefore, in the care of an intelligent mother, 
and in the society of its brothers and sisters, we should not send it to 
an infant school, where it is governed by, and associated with, stran- 
gers, with none of whom it is likely to have natural sympathies. 
What the child may be expected to gain specifically in these schools, 

ginning to prevail ; and especially that they have been adopted by the Select Com- 
mittee of the House of Commons in their late report on Education in Ireland. In 
this masterly document, which we understand to be the work of Mr. Wyse, music 
is included among 1 the subjects of instruction in the proposed elementary schools. 
[Note to 3d Edition.] 
6* 



66 PECULIARITIES OF DISEASE IN CHILDHOOD. 

beyond mere protection, can only be regularity of habits, which cer- 
tainly is of great importance, but not so great as to countervail the 
advantages of a well-regulated domestic circle. For the reasons we 
have advanced, we conceive that infant schools, though most service- 
able in large cities for the poor, are totally unfitted for the children 
of more opulent parents. With the latter, the system might be cha- 
racterized, as Dr. Chalmers has done another artificial system, as " a 
taking to pieces of the actual framework of society, and reconstruct- 
ing it in a new way or on new principles — which is altogether fruit- 
less of good, and often fruitful of sorest evil, both to the happiness 
and virtue of the commonwealth.' 7 * 






CHAPTER IV. 

PECULIARITIES OF DISEASE IN INFANCY AND CHH.DHOOD. 
I. ETIOLOGY. 

The great activity which pervades the whole body in the child, 
united to the peculiar susceptibility of the nervous system, and the 
abundant supply of bloodvessels, more especially arterial capillaries, 
predispose, in a particular mariner, to the sudden occurrence of dis- 
ease, its rapid progress, and frequently fatal termination during in- 
fancy, when organic change so readily takes place. 

In addition to this general activity, necessarily connected with the 
process of general growth, we observe a peculiar state of excite- 
ment or increased action in particular parts of the body at certain 
periods of growth, when these parts are found in a special manner 
to undergo rapid development, and are hence peculiarly liable to 
become diseased. Thus, the brain is undergoing a particularly 
rapid process of growth about the time that dentition commences, or 

* Since writing the above, we have had the pleasure of reading an interesting little 
treatise on Infant Education, published in Chambers' Educational Course. Edin- 
burgh, 1836. At the same time that we are most gratified to find that the princi- 
ples which we have attempted to lay down for early education, are those sanctioned 
by the experience of Mr. Wilderspin and others, still we cannot change our opinion 
with respect to the class of society for which the infant school is really adapted ; 
and we must be excused for preferring the family circle, as a place of education for 
the very young, in all cases in which it can be made use of without important 
sacrifices. We do not agree that the element of numbers, as Messrs. Chambers 
assert, is indispensable for exercising the social virtues of the child, particularly of 
the female child ; but we acutely feel, that a tenderness, not less than parental, is 
required to keep unceasingly awake the sense of responsibility which ought to be 
felt by the infant's instructor: and we conceive that this responsibility is intended, 
by a wise Providence, not merely for the child's advantage, but also for a strong 
and wholesome check upon the morality of the parent, which it would not be be- 
neficial to society to weaken by division, in any case admitting of its being left 
whole and undivided. [Note to 2d Edition.] 



ETIOLOGY. 67 

the teeth first begin to appear ; and at this very time we find the mucous 
membrane of the intestinal canal also making an important progress 
in development, the mucous follicles, or glands, beginning now 
rapidly to be evolved ; so that independently of any morbid action, 
set up directly in connection with dentition, we have the nervous 
system naturally in a high state of susceptibility, about the period 
of its occurrence, and the intestinal mucous membrane in a condition 
of peculiar irritability. All this it is important to keep in mind the 
better to be able to meet the contingencies of this period ; for these 
are mainly connected with this peculiar condition of the cerebral and 
abdominal systems, independently of the process of dentition, to 
which, however, it is the popular practice to attribute all mischances 
occurring at this age ; an error not less unfounded than injurious, 
and against which we would, in a special manner, warn the young 
practitioner. 

If one source of diseased action be a plus of vitality in any organ, 
as Broussais has taught, or an over-exercise of the natural function, 
in no subject is disease from such a source so likely to be found as 
in the child. This great activity of all organs and functions, how- 
ever, while it predisposes parts so much to take on diseased action, 
confers at the same time a peculiar energy or power of reparation, 
in virtue of which the danger in infantile disease is in a particular man- 
ner diminished, when once the acute stage of the disorder has been 
subdued, or has subsided. Thus the danger in infantile complaints 
is principally from the rapid occurrence of organic change, with 
fatal result, in the first instance, — the establishment of chronic disease 
being less liable to occur than in the adult, and more easily pre- 
vented ; while, should such take place, the child has more chance of 
recovery, no matter to what extremity it may have been reduced. 

The great nervous sensibility of the infant, and consequent irrita- 
bility, is a prime source of disease, and gives a particular character 
to all disorders occurring in the child. Irritation is easily set up in 
any organ, by causes acting directly or indirectly upon it ; and 
indirect or sympathetic irritation is very liable to occur in the child, 
particularly in certain organs, and is often presented in a very severe 
form. The most common seat of irritation arising from a cause 
directly applied, is in some part of the alimentary canal, and this 
is generally induced by the ingestion of unwholesome aliment. The 
presence of any irritating matter in the stomach or bowels of a child 
gives rise to symptoms often very formidable, particularly when it 
occasions sympathetic disturbance in the brain. The intestinal mu- 
cous membrane itself soon takes on the irritative action, and becomes 
the seat of disease ; the attendant symptoms generally assuming the 
type of remittent fever. The suffering caused by difficult dentition 
is a familiar example of direct irritation, which, though slight in 
itself, may occasionally lead to most serious results, by sympathetic 
disturbance of important organs. 

The lung may be directly irritated ; but often are sympathetically 
so, as when disease has existed in the abdomen or occasionally in the 
head. The cough in the first case will be irritative, generally pro- 
tracted, and may be violent 5 it is in the second usually spasmodic. 



cs PECULIARITIES OF DISEASE IN CHILDHOOD. 

The brain is less liable to irritation from any cause acting directly 
upon it, but often takes on this state, sympathetically, in consequence 
of disease in the digestive organs, or during the existence of protracted 
thoracic disease, especially if the cough be violent, as in pertussis. 

From the observations we have been enabled to make, we would 
conclude that the head sympathises most directly with the digestive 
apparatus, less so with the chest. The lungs sympathise frequently 
with disordered state of the bowels, less frequently with disorders of the 
head. The digestive organs sympathise readily with all the others, 

— remittent fever arising during almost all protracted diseases of 
childhood, as we see in most of the severe forms of pulmonary com- 
plaint ; and the stomach and bowels are immediately affected on the 
occurrence of irritation or inflammation of the brain. The mucous 
membrane of the bowels, in particular, sympathises with the cuta- 
neous surface, many diseases of which arise from disorders of the 
digestive tube. 

In the infant, irritation, whether existing primarily or only set up 
as a secondary occurrence, readily passes into congestion or inflam- 
mation. In the brain, in particular, congestion often arises suddenly 
during states of irritation ; or inflammation quickly follows the latter 
condition. 

The greater number of the diseases of childhood are inflammatory, 
and inflammation in the child is generally very severe, and often 
runs its course rapidly, giving rise to remarkable morbid productions. 
Exudations of lymph, or other matters, are quickly thrown out, and 
occur in situations where they are not liable to be found in the adult 

— on the mucous membrane, for example, as we see in croup. Effu- 
sions readily occur in serous membranes, as the arachnoid ; and soften- 
ing or ulcerations take place in the mucous membranes, as we find 
throughout the whole tract of the intestinal canal. Inflammation 
in the healthy child exhibits, in a particular manner, its tendency to 
end in the formative process, or the effusion of coagulable lymph, 
especially when situated in serous membranes ; but when occurring 
in the unhealthy subject, or towards the sequel of febrile disorders — 
as the exanthemata — the tendency is to serous or sero-albuminous 
effusions. 

Plethora is frequently present in the child, and is often the result 
of over-feeding ; but does not necessarily give rise to disease, as it 
does in the adult, the redundant material being consumed in the active 
processes of growth ; excretion being naturally much exceeded by 
supply at this period, and general corporeal increase the necessary 
result. 

The full fat child is a natural and wholesome object, and not so 
prone to disease as the pale, slender subject of misguided solicitude, 
that has been doctored into delicacy, and which, though not so vio- 
lently affected by inflammatory disease when attacked, is more ex- 
posed to illness, and more liable to protracted affections and relapse. 
It is in the child, reduced to a state of anaemia, by previous illness, 
mismanagement, or mistreatment, that we meet with the most formid- 
able maladies, and find all maladies presented in the most formidable 
forms. 



ETIOLOGY. 6 9 

Morbid action once set up in the mucous membrane, shows a 
marked tendency to spread or extend itself along the course of this 
membrane, in a manner that not only constitutes a peculiarity of dis- 
ease in the child, but becomes a serious source of danger. Thus 
ulcerations or inflammation of the membrane of the fauces or pharynx 
are liable to extend into the oesophagus, or, more especially, into the 
larynx and trachea. The exudation thrown out in croup, tends to 
extend down the air-passages ; and even common inflammation of 
the bronchi often shows so strong a disposition to spread universally 
over the bronchial surfaces, that the danger of the disease in the 
infant is much more commensurate with the extent of surface thus 
occupied, than with the intensity of degree in any one place. So of 
the gastro-intestinal mucous membrane ; it being equally remarkable 
here, that the tendency to spread is downwards along the mucous 
membrane, but seldom in the opposite direction. 

Metastasis, or transference of diseased action from one part to 
another, is particularly liable to occur in the child — hence the popular 
dread of the disappearance, or going in, as it is called, of eruptions, 
exanthems, &c, &c, — which apprehension, however, is commonly 
carried too far, and leads to very erroneous practice. We must, how- 
ever, shun the sudden suppression of inflammatory action going on 
in the skin, whether attended with fever or not, — as the eruption 
of measles, scarlet fever, extensive itch, or other cutaneous disease, 
— for this is often followed by morbid action set up in the alimentary 
canal, chest, or head. The first is perhaps most common ; but in 
measles, the chest is often attacked under such circumstances, and at 
the close of scarlatina, the head. The suppression of an accustomed 
discharge, as chronic diarrhoea, may have the same effect ; and this 
appears but natural, when we recollect the great susceptibility of the 
system, and the power of counter-irritation in the child. 

Disorders strictly to be called nervous do not occur in childhood, 
though the nervous system is so susceptible and so subject to disturb- 
ance ; but this usually displays itself in spasm or convulsion, and 
arises directly from morbid action going on in the brain or spinal 
marrow, or sympathetically, in consequence of disorder of the diges- 
tive organs. Convulsions occur in the infant, and epilepsy or chorea 
in the child: the latter, in particular, about the fourth or fifth year; 
but nervous affections, such as hysteria or hypochondriasis, are not 
to be seen at this age, neither do we often meet with neuralgic pains. 

Mental impressions, so fertile a source of disorders of the nervous 
system in the adult, do not in the same manifest manner effect the 
child, who, little disposed to anticipate evil, and quickly forgetful of 
past suffering, is possessed of spirits equal and lively, nor disturbed 
by disorders of the imagination. Yet the deteriorating influence of 
the depressing passions upon the health may be witnessed in the pale 
and dejected appearance of children who, through a mistaken zeal, 
are subjected to an over rigid discipline ; or, we may behold painful 
examples of what may be termed infantile nostalgia, among children 
recently removed to our public schools ; — the young heart appearing 
to pine in vain for " home and all its charities." Fear or anger, if 



70 



PECULIARITIES OF DISEASE IN CHILDHOOD. 



sudden or violent, may produce serious consequences. We have 
seen dangerous cerebral irritation thus excited ; and fatal convulsions, 
or idiotcy for life, have been caused in the child by a sudden fright. 

Some disorders are congenital, or may be born with the infant, as 
syphilis, and occasionally hydrocephalus ; as also affections of the 
alimentary canal. Some are peculiarly liable to occur immediately 
after birth, as purulent ophthalmia; while trismus nascentium is 
restricted in its period of invasion to the first nine days, never appear- 
ing after that period. 

There seems to be an hereditary predisposition to the occurrence 
of certain disorders, as croup, and hydrocephalus, among the children 
of some families ; all or most of whom are in succession attacked, and 
that often about the same age. 

The common causes of disease affect the child with more severity, 
in general, than the adult ; but from some the infant is perhaps free. 

Irregularities of diet, or improper food, constitute one of the most 
frequent sources of illness in childhood ; and derangements of the 
stomach and bowels, which are so liable to be thus induced, lead to 
serious results at this period of life. We have noticed the liability to 
dangerous sympathetic affections, particularly those of the head. 
Fever of an obstinate character, and generally of remittent form, is 
thus induced ; and inflammatory affections of the abdominal viscera 
have their frequent origin in this cause. A single indigestible meal 
will cause flatulency and acidity to an inordinate degree, soon to be 
followed by diarrhoea and more serious consequences. Such occur- 
rences take place frequently at the time of weaning ; and we should 
always make inquiries on this point, when an infant suffering under 
such symptoms is brought to us. Indeed, so common a cause of 
infantile disease is disorder of the bowels, that many have regarded 
it as the sole source of children's disorders.* 

Impressions of cold or damp, or vicissitudes of temperature, the 
most fertile source of disease at all periods of life, are particularly so 
with the child : this we were prepared to expect, having seen that 
the infant has but low powers of generating heat, and so of resisting 
the injurious effects of cold, especially when associated with damp- 
ness. During sleep, in particular, (when these powers are at the 
lowest degree ; some depression both of circulation and innervation 
being then present,) there is a susceptibility of the injurious influence 
of sudden alternations of temperature ; and to such the infant is espe- 
cially exposed, much of its time being passed in sleep, even in the 
open air ; and, when in bed, it often throws off the clothes, while 

* Etmuller, in his " Valetudinarium Infantile," attributes the diseases of the 
first year to some peculiar alteration in the digestive system ; Harris regarded acid- 
ity as the chief cause of infantile disease ; and Sydenham attributed much to this 
cause, combined with debility. The increase of mucus consequent on intestinal 
irritation, we have already noticed ; and this, Dr. Armstrong assigns as a prime 
source of infantile disorders ; but erroneously, as it is to be regarded rather as a 
provision of nature, to protect the membrane from the injurious impression of im- 
proper ingesta, and relieve it by evacuation when irritated thereby, or from any 
other cause. •" J 



ETIOLOGY. 71 

warm or, it may be, perspiring. Here we have the origin of many 
inflammatory affections, particularly of the throat, chest and abdomen. 

Some forms of disease are said to arise often, in certain situations, 
in consequence of the lowness and dampness of the place, as croup, 
or even hydrocephalus, which latter is looked upon as almost ende- 
mic in the Valais, where the best effects result from the removal of 
children from the district. 

Want of light and air is an abundant source of ill-health in chil- 
dren, and consequent delicacy of constitution in the adult. Thus is 
scrofula commonly generated or called forth, and all epidemic diseases 
aggravated or spread. To such sources of malady, however, the 
children of the poor, especially in large cities, are sure to be exposed ; 
and the detriment to the common weal arising from this cause, 
though now little noticed, is such as well to deserve national con- 
sideration.* 

We have paid particular attention to the influence of season, or 
states of the atmosphere, in generating or modifying peculiar forms 
of complaint in the child, and have found this influence to be most 
remarkable, so much so, as to cause an established uniformity in the 
variety of inflammatory affection prevailing at different periods of the 
year. This variety generally arises from a different tract of the mu- 
cous membrane being affected at different seasons ; and a degree 
of uniformity or order seems to be observed in the course of this mor- 
bid migration, which may be seen to commence with the nose and 
mouth, coryza and catarrh prevailing generally among children at 
the beginning of winter. Bronchitis, and the severer forms of pul- 
monary inflammation, appear as the winter advances, and prevail 
during the spring, especially in the earlier months. As summer 
approaches, disease lessens, and pulmonary affections nearly disap- 
pear ; but as the season advances, the seat of disorder changes ; and 
now the gastro-intestinal mucous membrane becomes engaged, and 
on the arrival of autumn, we have diarrhoea, dysentery, or cholera, 
constantly presented to us in the sick child ; the tendency of disease 
to spread downwards along the mucous membrane, as already noticed, 
being here again to be observed. From attention to these particulars 
we may derive some information as to the nature of a child's disease, 
when it is only complaining, or out of order. 

Autumn and winter seem to be the most unhealthy seasons, sum- 
mer and spring less so ; but this rule does not hold good alike in all 
towns, and occasionally much illness obtains during spring. At this 
season some epidemic usually prevails, and we most generally meet 
with one of the exanthematous disorders to which children are sub- 
ject. It is a more favourable time for the occurrence of such, how- 
ever, than the winter months, as the approach of summer facilitates 
recovery during convalescence. 

It has been doubted whether the very young child is susceptible 
of contagion; but infants have been born covered with small-pox, 
and are said to have come into the world afflicted with hooping-cough ; 

* See p. 54. 



n PECULIARITIES OF DISEASE IN CHILDHOOD. 

and we know that they mav be affected with these complaints at the 
very earliest age. Continued fever is a very rare occurrence m the 
young child, being seldom, if ever, seen before the third or fourth year. 
Daring the prevalence of fever in the winter of 1838, however, we 
saw an unusual number of cases of fever in children, which was, in 
several instances, obviously received by contagion, and presented 
characters similar to those of the fever in the adults from whom it 
was taken, although there is no doubt that young children are not so 
susceptible of the contagion of fever as adults ; nor is the disease so 
fatal to them as after the middle period of life. 

Fever usually presents itself in the child in the form of symptomatic 
fever, or constitutional disturbance, attendant on some inflammatory 
affection, seated in one of the great cavities, most frequently in the 
abdomen. This form of fever usually assumes the remittent cha- 
racter, and may be presented in a severe degree in the more grown 
children; but it is remarkably modified by age, and the seat of the 
affection of which it is symptomatic; little or no constitutional dis- 
turbance being, at times,' present in the very young infant, or before 
the sixth or seventh month; even though extensive morbid action may 
be going on, particularly in the abdomen. 

There is a particular class of febrile diseases which spread epide- 
mically, if not by contagion ; as measles, hooping-cough, &c, that 
are peculiarly liable to occur during childhood, and generally prevail 
among many children at the same time. These disorders run a 
certain course, or last for a particular period ; and during their pro- 
gress, are liable to become complicated with some phlegmasia or 
local inflammation, whether occurring coincidently with the invasion 
of the disease, or arising during its progress, thus inducing inflam- 
mation during fever, the reverse of what takes place in the class of 
febrile complaints just considered. Such complication is particularly 
liable to occur in measles, which often sets in with bronchial inflam- 
mation, or soon becomes complicated therewith. The same often 
occurs during the course of hooping-cough. In scarlatina, gastric 
affections are liable to arise ; or cerebral inflammation may set in 
suddenly, at the conclusion of the disease ; to say nothing of the 
ordinary attendant inflammation of the throat. In small-pox, the 
pleura may be suddenly attacked by inflammation, although the 
abdomen is most frequently the seat of disease — but in all, these 
complications occur most frequently in very young children. These 
complaints are sometimes represented as peculiar to infancy and 
childhood, and the individual once affected is said never to have the 
disorder again. The same individual, however, may have any of 
these complaints a second time ; but this is rare, though it occasion- 
ally happens, as with scarlet fever, and even small-pox. The adult 
is certainly less liable to take these disorders than the child ; but we 
have seen a person of seventy, in hooping-cough, and a mother will 
occasionally take measles from her own offspring. Of these com- 
plaints, small-pox is that which has least of an epidemic character, 
being the most decidedly propagated by contagion ; and is hence, 
perhaps, to be looked upon as less peculiarly a disease of childhood 



ETIOLOGY. 73 

than the others. It is desirahle that such diseases should have been 
passed through in early life ; and we may be consulted as to the 
prudence of leaving a child exposed to any of these complaints, or 
removing it for security. If the child be healthy, and the type of the 
prevailing epidemic mild,* it will in general be best to allow the 
child to remain ; but when the infant is delicate, teething, or only 
recovering from a former illness, and under any circumstances, when 
the type of the prevailing disorder is severe or malignant, it will be 
advisable to take every precaution against the malady. It is well, 
also, to keep in mind that contagion is most liable to be communi- 
cated at the decline of these complaints, after maturation has taken 
place, and while desquamation is going on. Hence, we may not be 
too late in separating children after the disease has actually appeared 
in a family ; but cannot, with any safety, permit them to come 
together on its decline, or too soon, during convalescence. 

Cutaneous diseases, to which children are so liable, from the deli- 
cacy of their skin, and the great sympathy between the cutaneous 
surface and the lining membrane of the digestive organs, partake 
not a little of the nature of the eruptive fevers, many running a regu- 
lar course, or stated period of increase, maturation, and decline ; 
while some are highly contagious, differing chiefly from the exan- 
themata in the absence of fever ; more unsightly than dangerous in 
their nature, when not mismanaged in treatment. We need not 
participate in the great horror in which diseases of the skin are held 
by the fond mother, who little likes to see the beauty of her offspring 
thus deformed ; while as far are we from agreeing with the ignorant 
nurse, who rejoices in the great good which the constitution is to 
derive from the coming out of the eruption. Some may be occa- 
sionally beneficial, as points of derivation to counteract cerebral, 
or oftener, abdominal irritation, or that induced by the process of 
teething; and a few are, perhaps, criacal. But none do we hesitate 
to remove after proper precautions ; and many, which, to ordinary 
means, prove most rebellious, will be found, in due time, to disap- 
pear, under a well regulated discipline. The protracted continuance, 
however, of most, does serious damage to the health, wearing out the 
child by constant irritation, inducing disorders of the digestive organs, 
and ultimately leading to a cachectic state, in which the glandular 
system becomes implicated, and mesenteric disease at length esta- 
blished. A few forms of disease of the skin appear only in infancy; 
some are most liable to occur during childhood ; and all are modified 
by the influence of that age : but a large class is to be found in the 
adult alone. The subject is one of so much importance, that we 
devote to it a distinct chapter. — (See Cutaneous Diseases.) 

Diseases of the urinary organs are not very frequent or formidable 
in the child ; but a disordered state of the urine often exists, and is 
easily induced by derangement of the digestive organs, when a deposit, 

* The type of an epidemic is not to be judged of by the character of a particular 
case, but by the general character of the complaint then prevailing; as very severe 
forms of disease may be communicated by a mild case; the opposite occasionally 
occurs. [Note to the 4th Edition.] 
7 



7 j PECULIARITIES OF DISEASE IN CHILDHOOD. 

mostly whit©, (appearing as the urine cools, or remaining after it has 
evaporated.) makes its appearance ; or the urine is passed white, in 
the first instance. Gravel often forms in the child, particularly in the 
children of the poor, or in the offspring of gouty and dyspeptic parents ; 
but this usually consists of lithic acid, and is presented in the state of 
a red deposit, or as an amorphous sediment, and passed without irri- 
tation ofthe urinary organs ; or in the form of crystallized lithic acid, and 
accompanied in its passage by irritation more or less severe. Atten- 
tion to these circumstances are most important, that we may, by timely 
interference, prevent the formation of calculus, to which children — 
at least, the children of the poor* — are peculiarly liable. The 
calculus will, in this instance, mostly consist of the lithate of ammonia, 
being generally of a clay colour and small size, as occurring principally 
in children. (See Prout on Diseases of the Urinary Organs.) 
Symptoms of dysuria, however, are not confined to cases of stone in 
the bladder, but will attend irritation or inflammation of that organ 
itself, or of the abdominal viscera, as in the adult. Even ischuria, or 
total suppression of urine, may originate in this latter cause ; or more 
directly from disease of the kidney. But an opposite condition, one 
of irritability — increased flow of urine, or incontinence, is what par- 
ticularly appertains to childhood, and is oftenest met with at that age. 
Dentition, so fertile a source of sympathetic irritation, not unfrequently 
displays its disturbing power in the urinary organs. A distressing 
state of dysuria attends the cutting of the teeth ; or more commonly, 
a great irritability of the bladder, with a frequent and copious flow of 
limpid urine. This symptom also attends nervous irritability, from any 
cause, in the child as in the adult. This flow of urine in the child we 
have seen antecedent to attacks of hydrocephalus : occurring, pro- 
bably, at that period when nervous excitement precedes inflammatory 
action. Incontinence of urine, however, is the morbid condition most 
incident to childhood, and confined more exclusively to that period of 
life. We have already noticed some anatomical peculiarities in the 
formation of the bladder, which, at this early period of life, predispose 
to this affection ; although it may, perhaps, mostly be looked upon as 
sympathetic of a deranged state of health, particularly disorder of the 
digestive organs. It occurs generally about the same hour towards 
morning, and only in bed, being very irregular in its time of duration ; 
but by no means confined to boys, as commonly thought, although 
much less frequent in the other sex. 

Scrofula is much a disease of childhood, though not confined to 
that period of life ; neither does it often make its appearance before 
the second or third year. It is about the seventh year, or the period 
of second dentition, that scrofulous affections become most manifest. 

* Sir Benjamin Brodie remarks, in his Lectures on the Urinary Organs, that the 
deposit of red sand which occurs in adults among the rich, is found principally in 
children among the poor ; among whom, also, children are much more liable to 
calculi than adult persons. And this from the same cause, though originating in a 
tlifierent source, namely, derangement of the digestive organs, caused, in the rich, 
by indolence and luxurious living ; but in the children of the poor, by unwholesome 
diet and neglect : so do extremes meet. [Note to 4th Edition.] 



ETIOLOGY. 75 

In the child, scrofula is particularly liable to display itself by attacking 
the glands of the neck ; and enlarged tonsils are frequently met with 
at this period of life ; but mere enlargement of the tonsils or cervical 
glands is not to be looked upon as necessarily originating in scrofula, 
or as constituting of itself evidence of its existence. Glandular disease 
is common at this age ; mumps, an affection of the parotid gland, 
occurs usually in childhood ; and even this is liable to be transferred 
by metastasis to other glands ; the testicle or the mammas. Enlargement 
of the mesenteric glands, leading to disorganization, and the establish- 
ment of tabes mesenterica, usually commences during childhood. The 
formation of tubercle in the child is not less remarkable than the 
liability to glandular disease, and both seem alike allied to a scrofulous 
taint or strumous diathesis, but the former has not attracted the atten- 
tion that it deserves. Infants have been born with tuberculous deposits 
in different parts of the body, and these in various stages of advance- 
ment, even to softening and ulceration. Tubercle seldom occurs in 
other parts of the body without being found at the same time in the 
lungs ; and true tubercular phthisis is a disease which we have not 
only seen in the young infant, but which appears to be an affection to 
which children are very liable, particularly about three or four years 
of age.* We have seen such cases regarded, to the last, as instances 
of remittent fever complicated with cough, and hopes thus held out 
which could not be realized. These tubercular formations are most 
liable to occur in the debilitated state of constitution following febrile 
attacks in children, or during protracted convalescence therefrom, and 
are often called into action by attacks of bronchitis, especially after 
remittent fever, measles, or scarlatina ; or when the system has long 
suffered from severe cutaneous disease. Hence, there is a particular 
danger in inflammatory affections occurring under such circumstances 
in children, or under any circumstances in those of a highly strumous 
habit ; such attacks being, in general, very insidious in their nature, 
not admitting of very active treatment, and appearing often to be 
connected with, or to end in, the formation of tubercle. — (See 
Scrofula.) This may occur even in cerebral inflammation in the 
child, a particular form of meningitis, hence getting the appellation of 
Tubercular. — (See Diseases of the Cerebral System.) 

The bones are often engaged in disease during childhood, and the 
scrofulous diathesis, which then so often obtains, doubtless contributes 
to this; but the greater vascularity of the osseous structure, also acts 
its part. If this contributes to the occurrence of disease, it also aids 
materially in its reparation ; for recoveries may be looked for in early 
life, that could not be expected at a later period. It is in early life 
that we meet with those alterations in the structure of bone, which 
tend to the production of personal deformities ; an early example of 
which we occasionally see in the deformed chest sometimes met with 
soon after birth, and known by the appellation of chicken-breasted — 
for a good account of which see Copeland's Dictionary of Medicine, 

* See Sir James Clarke's valuable " Treatise on Consumption and Scrofula," 
p. 171. 



~q PECULIARITIES OF DISEASE IN CHILDHOOD. 

Article, Chest (Deformities of). But more usually, aud at a later 
period, we meet with distortions of the limbs, spine, or joints. These 
occur mostly where the strumous diathesis prevails, when the bodies 
of the bones are liable to be affected with rickets; or their articular 
extremities involved in the disease. Acute inflammation, on the con- 
trary, seldom attacks the articular extremities of the bones in children, 
though not unfreqnently seen in the femur or tibia ; being the common 
cause of necrosis in these bones. In consequence of the great vascu- 
larity of bone, fractures unite with certainty and rapidity ; and the 
greater softness of the osseous matter, also imparts the peculiarity, 
that partial fracture, or only bending of the bone, may take place ;* 
while, from anatomical peculiarities, some fractures can scarcely 
occur, as, for example, that of the neck of the femur. This power of 
yielding without being fractured, is remarkably exemplified in the 
bones of the head ; for a depression will occasionally be found in the 
skull of the child from injury, which is in truth a mere bulging in, not 
fracture, and which will ultimately disappear without the interference 
of art ; but which could not have taken place in the adult, without 
the bone giving way. The power of spontaneous rectification in cases 
of fracture, is also remarkable ; for, however crookedly united, the 
bone has a tendency in the child to become straight, and will occa- 
sionally do so completely, even in bad cases. 

A similar power of reparation exists in the soft parts ; but great 
losses of blood are ill borne by the child ; and the peculiar suscepti- 
bility of the nervous system, which gives such a tendency to the rapid 
supervention of depression or sinking, makes the shock from opera- 
tions and injuries always dangerous — it may be fatal. Hence, sur- 
gical operations are generally objected to till after the third month. 

II. DIAGNOSIS. 

It is particularly necessary to be versed in the diagnosis of infan- 
tile disease, as our chief prospect of success, in acute cases, depends 
on an early discrimination, so as to be able promptly to apply the 
necessary remedies; nor can we in the more chronic, "hope for'suc- 
cess, until we have accurately determined the seat and nature of the 
malady, and particularly whether it be a primary or secondary affec- 
tion ; while the little patient cannot in general give any information 
itself, or only such as is likely to lead astray. 

This loss, however, will be the less felt, if we pay sufficient atten- 
tion to the information conveyed by the physical signs in infan- 
tile disease, the appearance of a child imparting more knowledge to 
the experienced eye, than any account given by attendants could 
convey. We shall always have occasion, however, to inquire from 
them the history of the case. 

The healthy child is cool, plump, and lively, the flesh firm, and 
movements free. It likes to be played with, and carried about. The 
abdomen is full and soft, and pressure upon it seems rather to please 

* See paper by Dr. Hart, in the Dub.. Med. Jour. vol. i. 



DIAGNOSIS. 77 

than annoy the child. The tongue in generally white, but not over- 
loaded ; and the mouth is always moist. It sleeps quietly on its side, 
with the limbs flexed, generally going to rest at the same hour.; and 
awaking cheerfully, soon demands food. It is scarcely necessary to 
add, that the secretions are natural and regular. Not so with the 
child when ill : it is more or less peevish — dislikes being stirred, 
or even cries when handled ; its hour of sleep is uncertain, and it 
rests ill, or awakes startled or crying. The skin is hot and dry, 
particularly the hands, feet, or head. The flesh is soft or wasted. 
There is thirst and a dry mouth, with unnatural appetite and de- 
praved secretions. 

When a sick child is brought to us, or we visit it, our attention 
should first be directed to the expression of the countenance, then to 
the attitude, state of the limbs, and skin. In the child in particular, 
the expression of the countenance or peculiar character of certain of 
the features, indicates a morbid condition of particular organs ; for 
at this age the muscles of the face are not endowed with much 
mobility, and the expression of the countenance is an index of phy- 
sical, rather than mental, operations ; sensation more than thought 
being expressed thereby. Three principal indications of physio- 
gnomy present themselves, connecting a particular set of features with 
one of the three great cavities — as we observed when speaking of 
the temperaments, and related in a similar manner. The expression 
of the upper part of the face, the forehead, eyes and brows, indicat- 
ing disease of the brain or nervous system ; the features of the middle 
of the face, in particular the nose, being affected by morbid conditions 
of the organs of circulation or respiration ; while abdominal affections 
are in a peculiar manner pointed out by the expression of the mouth 
or state of the lips.* We next proceed to examine more minutely 
into the several symptoms, — to determine the seat of the disorder, 
whether in the head, chest, or abdomen, — and its nature, or the 
particular lesion on which it depends. 

When the brows are knit, the eyes fixed and staring, or looking 
wild or vacant, our attention is at once directed to the head. We 
try whether it is unusually hot, the vessels full or in over-action, 
and examine the fontanelle, to see if it be depressed, or in a state 
of distention. We now observe the attitude, and see whether the 
child's head hangs heavily on the nurse's arm, or rolls from side 
to side, sunk upon the pillow ; and try whether the neck be stiff, or 
retracted, which it occasionally is. We observe or inquire whether 
the child puts its hands to its head, as in health infants seldom raise 
the hand above the mouth. We examine the limbs, to see whether 
they be rigid or relaxed, — lying motionless, or tossed about, and 
affected with spasm — in particular, we try whether the hands are 
clenched, and the thumb turned in, or toes bent. According as the 
upper or lower extremities are affected, one or both, an indication is 
given as to the seat and extent of the disease. The state of the 

* M. Jadelot has treated this subject with ingenuity and elaborateness, but we 
have not been able to discover all that he points out. 

7* 



7S PECULIARITIES OF DISEASE IN CHILDHOOD. 

pupil next demands investigation. It may be found contracted and 
the child will start, as if frightened, or scream out, on being touched ; 
or the pupil maybe dilated and insensible to light,— the child being 
motionless or unconscious. We shall hear that the child hashadstart- 
ing in its sleep, grinding of the teeth, or movements of the lips ; and 
that when awakened, it started up affrighted, or screamed out ; the 
bowels are obstinately costive, or the evacuations very foul and dark- 
coloured. The hands are usually hot, but the feet Cold ; and one 
cheek is often deeply flushed. No doubt can now exist that the 
head is the seat of disease ; but what that particular disease may be, 
and whether a primary or secondary affection, is to be determined 
by symptoms hereafter to be detailed, in their proper place. 

" Occasionally we see a child lying completely prostrate, the limbs 
being relaxed and motionless, the belly sunk, and the eyes fixed, 
with the lids half-closed ; we are told, however, that it is now much 
better than it was, as it had been affected with convulsions which 
have quite ceased ; and no suspicions seem to exist that it is in the 
last stage of cerebral disease, — the attendants actually congratulat- 
ing themselves on its quietness. It is not uncommon to find one or 
more of the extremities quite paralytic in the young infant, without 
any notice having been taken of the circumstance. 

There is another expression of countenance very different from 
that last described, but which denotes much suffering. The lips are 
retracted, or drawn, so as to show the teeth or gums ; the counte- 
nance is pale, or sallow and sunk ; the child seems to dread motion, 
lies on its back, with the knees bent or drawn up, and is pained by 
pressure on the abdomen. Here neither the brow is knit, nor the 
pupil of the eye affected. The skin is very hot, shrivelled, and 
harsh ; there is much wasting, great thirst, particularly for cold water, 
and a distinct diurnal exacerbation. The tongue is loaded, or dry, 
red, and pointed ; aphthse may be present ; and diarrhoea constantly 
attends, — the stools being generally thin, green or dark brown, and 
fetid. The abdomen is here obviously the seat of disease ; and such 
a state of things often occurs at the period of weaning, as the state 
before depicted does during dentition. 

In the autumnal season, we often see an infant lying sunk in the 
nurse's arms, the* face pale, the features sharp, the lips apart, and 
the countenance betokening distress ; it may be that the eyes are 
sunk, and the skin around them, as also the lips, dark-coloured. On 
our first query, we will be told that the child has vomiting and purg- 
ing ; but a look must be sufficient to tell the experienced eye that 
this is a case of infantile cholera. 

When a child coughs, the eyes are red, and the nose runs, with 
sneezing or snuffles, we know that it has a catarrh, but cannot say 
whether it may not be getting measles, or some epidemic then pre- 
vailing : we should, therefore, be cautious in our diagnosis, until the 
case has shown some more determinate symptoms. 

Cough is a usual attendant, on affections of the chest, and cough 
in-the child is often violent or spasmodic. In the young infant, how- 
ever, we must recollect that pertussis may be present without any 



DIAGNOSIS. 79 

whoop. When the larynx is the seat of disease, the cough will be 
acute or hoarse, according as inflammation or ulceration be present, 
and almost always spasmodic. The peculiar crowingcough of croup 
is an important diagnostic, which cannot be too early recognised. 
The young child almost always swallows any matter expectorated, 
and therefore this can scarcely become an object of diagnosis. Some 
of the false membrane in croup, however, is occasionally coughed up. 
We should always recollect the influence which the expectoration 
swallowed may have on the stomach and bowels, and allow for the 
effect which it must produce on the appearance of the stools. 

The quantity of mucus thrown out, on even slight irritation of the 
mucous membranes, sufficiently accounts for the loud wheezing, or 
rule heard during the existence of pulmonary inflammation in the 
child ; but this circumstance alone need not cause the alarm it often 
does. 

The indications afforded by percussion and auscultation in the 
child differ, in some respects very materially, from those in the adult, 
even in the same disease, while they often are very difficult of attain- 
ment, and not always of equal certainty as signs of disease. Hence, 
the use of the stethoscope in the pectoral diseases of children, must 
be studied as a distinct subject in itself; and will require to be 
actually practised before it can be correctly understood. 

Antecedent to the information to be derived from auscultation, 
however, we have intimation from the expression of the countenance, 
and attitude of the child, as to the chest being the seat of disease. 
When acute or extensive inflammation is present, the respiration is 
hurried, the countenance discoloured, the eyes more or less staring, 
and the alae nasi dilated or in quick motion. Respiration is carried 
on more or less by the aid of the diaphragm and abdominal muscles ; 
while the thorax remains comparatively quiescent. On the contrary, 
when the abdomen is the seat of the inflammation, it is by the 
thoracic muscles that respiration is carried on, the abdominal remain- 
ing quiet, and the alee nasi unaffected, though the breathing be hur- 
ried. The deep depression noticed at the scrobiculus cordis and the 
upper part of the sternum, when respiration is very difficult, indicates 
a severe degree of pleuro-pneumony ; but our intention here is not to 
forestal the diagnostics of particular diseases of the chest, but to 
furnish a general sketch by which thoracic diseases may readily be 
recognised and distinguished from diseases of the other cavities. 

It is very necessary, but often difficult, to determine the existence 
of pain and its seat in the child ; or the cause that may make an 
infant cry. The character of the cry will vary according as it arises 
from acute suffering or not, and will also be modified by the age of 
the child. In the young child, especially, when fresh and robust, the 
cry that arises from acute suffering is clear, loud, sounding, and con- 
tinuous, and has been remarked as belonging more to the expiration, 
than inspiration ; the latter being in this case short, and lost, as it 
were, in the former > when the child is feeble or fatigued, however, 
and cries more from annoyance than suffering, the cry of inspiration 
seems to prevail, being longer and more marked, especially as the 



SO PECULIARITIES OF DISEASE IN CHILDHOOD. 

child grows older. There is also in this case more of sobbing, and 
sighing ; and the circulation is little if at all accelerated. A hoarse 
cry, if not caused by exhaustion, should cause attention to the state 
of the larynx, more particularly if the cry be dry and husky, such 
being caused by an erythematous or aphthous condition of the organs 
of voice. A peculiar ringing sound in the cry is often our earliest 
warning of the approach of croup or spasm of the glottis — the sound 
of the cry in the child supplying those indications which we derive 
from the voice in adults. The shrill peevish scream that characterizes 
the advanced stage of hydrocephalus can hardly be mistaken ; but in 
general the pain of acute inflammation rather checks than excites 
crying in the child, alow moaning or sighing being rather the sounds 
of distress that belong to that state. To determine the seat of the 
pain, we observe whether the child puts its hand to the head, throat, 
or other place, as if indicating distress ; and if this indication be cor- 
roborated by other symptoms, and it does not appear that the child 
is hurt by any thing in its dress, we may consider that part to be a 
seat of suffering. We have thus been led to detect otitis in the infant, 
when its cries could not otherwise be accounted for. We must be 
cautious not to credit a child's statement of having pain (or, as it 
generally expresses it, i being sick,') in the head, stomach, or else- 
where, without getting it to point to the part complained of, but 
which it often misnames. The peculiar expression of the counte- 
nance also assists us : the brows being contracted, when the uneasi- 
ness has its seat in the head ; the lips drawn and apart, when in the 
abdomen ; and the alae nasi in motion, when the respiration is im- 
peded and painful. 

The softness of the muscles or degree of emaciation to which a 
child is reduced, are important in diagnosis, but not to be judged of 
by merely regarding the face : this may appear full and firm, and yet 
the rest of the body be much reduced.* In mesenteric disease, the 
emaciation proceeds steadily, but may be slow in progress. Derange- 
ment of the intestinal mucous membrane is soon attended with 
softness and wasting of the muscles ; the body of the child wasting 
much more rapidly than that of the adult, under the influence of any 
cause that impedes digestion. In protracted cases the emaciation 
becomes extreme — the skin growing harsh, dry, wrinkled, and dis- 
coloured ; and the countenance often assuming an appearance of old 
age that looks almost unearthly. 

When consulted respecting cutaneous disorders in children, it is 
important to be able to determine which are contagious and which 
are not ; and in particular, we should make ourselves familiar with 
the forms in which psora or itch may be presented, as it appears 
often in a very severe form and has been taken for a syphilitic erup- 
tion ; while syphilis is at times overlooked, and the child perishes 
before the true nature of the disease is discovered. 

"W Th c e ° bservant nu ^e, curious in such matters, will point out the firm or flaccid 
state ot the scrotum as the best indication of good or bad health. [Note to the 4th 
Jcidition.j L 



PROGNOSIS. si 



III. PROGNOSIS. 

Determining the nature of a disease will often at once decide our 
prognosis. Thus trismus nascentium is almost necessarily fatal : and 
a particular form of hydrocephalus generally so; while syphilis, 
however severe in the infant, may almost certainly be cured : and 
so of other diseases. 

In no class of complaints is correct diagnosis of more importance 
than in children's, as so much of the danger arises from their not 
being distinguished in sufficient time to allow of a prompt employ- 
ment of remedies. Thus all acute inflammatory affections are highly 
dangerous in themselves; but if seen sufficiently early and detected, 
our prognosis may be favourable, so influential will always be found 
adequately active and judicious treatment. When the acute stage 
has passed by, or been subdued, we have again excuse for a hopeful 
prognosis, even though some organic change may have taken place ; 
so vigorous in general is the infant constitution, and such powers of 
reparation does it possess. 

Generally speaking, we may say that, however severely a child 
may be affected in the first stage of an acute disorder, or to whatever 
extremity it may be reduced in the progress of a protracted one, it 
will be wise not absolutely to give up hope, however guarded our 
prognosis may be. Few who had not witnessed it, could credit the 
immediate benefit to be derived from the employment of sufficiently 
energetic means in the early stages of the severer forms of infantile 
disease ; or the apparently moribund state from which a child may 
be restored by judicious management. One evil arises from early 
despairing of a child, which the practitioner should keep in mind and 
guard against. The attendants, who are always ready to give up 
administering medicines, which they often look on as only a source 
of annoyance, will from that time do nothing; and thus children are 
allowed to perish for want of proper perseverance in the administra- 
tion of the remedies prescribed. 

On the other hand, we should inquire carefully as to the plan of 
treatment that has been pursued with a child which has been long 
ill, and which may be brought to us in an apparently hopeless state, 
and, before we pronounce an opinion, see whether that state be not 
owing more to the remedies employed than the original disorder. 
Thus we often see children run down to the last extremity by inces- 
sant purging, which will almost of itself cease, if the little powders 
which it has been for so long a time taking, be but discontinued: 
these powders almost invariably consisting of calomel, or some other 
irritating medicine. Or, a child which appears to be in the last stage 
of hydrocephalus, may be found, on examination, to have been 
brought into this state by the excessive evacuations to which it has 
been subjected : and of course, the mistake being discovered, our 
prognosis may be more favourable than it otherwise would be. 

Again, if we find our efforts to subdue inflammatory action inef- 
fectual, though apparently sufficient for the object proposed — that 



S2 PECULIARITIES OF DISEASE IN CHILDHOOD. 

in fact the child, though relieved after each application, is again 
quickly thrown back, — we may suspect improper interference on 
the part of attendants, who are usually in dread of the little patient 
being too much weakened. By at once charging them with the 
delinquency, or expressing our opinion that now some stimulant 
would be beneficial, we shall in general obtain a confession, made 
either in contrition or exultation — the attendants owning their fault, 
or boasting of their sagacity in knowing that wine or spirits was re- 
quired, and having administered it accordingly. Having thus dis- 
covered the source of failure in our remedies, our prognosis may 
consequently improve. 

We have noticed the liability to the occurrence of sympathetic 
affections in the child. In such affections there is less danger than 
the same symptoms would indicate did they belong to a primary 
disease, particularly when the true nature of the case is early de- 
tected, and the original source of disease removable. We must 
keep in mind, however, that functional disorder, if continued, will 
change into organic disease, and that the secondary affection may 
thus become more formidable than the primary, which must influ- 
ence our prognosis accordingly. This tendency to sympathetic 
affection, or disease arising secondarily during the progress of any 
disorder, in the child, is in itself a particular source of uncertainty 
and danger; and must make us always guarded in promising abso- 
late recovery in any complaint that has to run a certain course, or 
shows a tendency to become protracted. Thus remittent fever, how- 
ever slight at the commencement, is liable to be tedious in its course ; 
and so time is allowed for the occurrence of sympathetic affections of 
the head or chest, which but too often supervene. In no disease is 
the necessity for this precaution better exemplified than in pertussis. 

We have already pointed out the greater liability of some of those 
sympathetic affections to occur than others. It now remains to 
notice the degree of danger with which these complications are liable 
to be attended. This will mainly depend on the facility with which 
the original disease may be removed, or the degree of interference 
with treatment which the complication involves. Thus the com- 
bination of pulmonary inflammation with gastro-enteritis, or the 
occurrence of either during the existence of the other, is particularly 
dangerous from both sources. When the head becomes engaged 
during the existence of pertussis, the danger is augmented in conse- 
quence of the persistence of the primary disease, which has to run its 
course ; and the occurrence of gastric, or intestinal irritation, during 
affections of the head or chest, adds much to the danger by embar- 
rassing the treatment; as the free use of aperients or antimonials is 
then precluded. 

The type of the prevailing epidemic will give us an early intima- 
tion as to the liability of danger, in many instances. There are times 
when measles and hooping-cough are comparatively mild complaints ; 
while, again, a most dangerous character, or malignant type, will, at 
some seasons, prevail ; so that to be attacked, is to be in danger. 

When an hereditary disposition to the occurrence of particular 



GENERAL OBSERVATIONS. 83 

diseases of childhood exists, such diseases when they do occur must 
be looked on unfavourably, and all preventive means should be 
adopted to avert them. The same rule holds good with respect to 
disorders arising from particular situations. 

One peculiarity in the symptoms of disease, as it approaches a 
fatal termination, is often manifested in the child in so remarkable a 
degree, as in a special manner to call for precaution, to prevent our 
being signally misled in our prognosis. We allude to the remission, 
or at times total suspension of severe symptoms, which occasionally 
precedes death, but by the unwary will be taken as the harbinger of 
recovery. In no instance is this more striking than in affections of 
the head in the child. Consciousness or even intelligence may be 
suddenly restored just as death was expected — but they prove to be 
only precursors of the fatal moment. 



CHAPTER V. 

INFANTILE THERAPEUTICS. 
I. GENERAL OBSERVATIONS. 

In nothing are the peculiarities of infancy more remarkable than 
in the influence which they exercise over the action and uses of medi- 
cines ; and of no subject is a special knowledge more necessary for 
the successful treatment of infantile complaints. Most medicines act 
with great energy on the child, and some have a peculiarity of action 
differing from that in the adult ; while all require to be given in 
diminished doses, regulated by the age. If attention be not directed 
to these points, the practitioner can hardly fail to meet with embar- 
rassment in treating infantile disease. 

An attempt was long since made by Gaubius to express with 
arithmetical precision the difference of dose according to the age ; 
and his table is useful, though not always implicitly to be followed. 
According to his arrangement, if the dose for an adult be one, half 
the quantity will be the dose at fourteen years of age, (or puberty,) 
and half this again, or a fourth, at four years of age, and half this 
again, or an eighth, at two years. Expressed in a tabular form, 
with the intermediate ages from childhood, the table will stand thus : 

Dose for an adult, 1, say 1 drachm, 

For a child 7 years old, £ — 1 scruple, 

4 ... ... ^ — 15 grains, 

3 -£ — 10 grains, 

2 ... ... £ — 8 grains, 

1 and under 1-12 to 1-15 — 5 or 4 grains. 



We have here a useful general index, and one of practical appli- 
cation, but to attain facility in prescribing and accuracy in adapting 
our doses to the different ages of childhood, attention must be paid 



S4 INFANTILE THERAPEUTICS. 

to the several medicines themselves, and the action of each dose 
watched so as to suspend the use of the medicine when the desired 
effect is produced ; or hasten its repetition when this is too long 
delayed. With children in particular, we avail ourselves of the ad- 
vantages to be obtained from administering medicines in divided doses, 
so as to ensure the result proposed, neither more nor less. Thus, 
opiates require to be given at first in very guarded doses, and the 
repetition of the dose carefully watched, while purgatives will often 
fail of their effect even in very young children, and unless the dose 
be quickly repeated, or the form of the medicine varied, much valua- 
ble time will, in some instances, be lost before the desired effect on 
the bowels be produced. To specify the precise dose of every medi- 
cine according to each year of age, would be but to attempt the per- 
formance of a tedious task, more calculated to complicate than to 
simplify the subject. Under the head of each medicine, however, 
we shall assign the doses for the earlier years of childhood; and sup- 
ply a set of formulas exhibiting suclneombinations of medicines as we 
have found most serviceable in the treatment of infantile disease. 
For the sake of uniformity we have made our mixtures to consist of 
two ounces, as a quantity convenient to order for a child ; and the 
doses prescribed are adapted to the two first years of life; after 
which they may be increased one-half until four years of age and 
then be doubled. 

The number of medicines which it is necessary or advantageous to 
give to the child is not great ; and still more are we limited as to our 
mode of administering them ; the liquid form or that of powder, being 
almost the only shape in which medicine can be given to the young 
child. No less important an object is it to render medicine as much as 
possible palatable to the taste, as all must acknowledge who have wit- 
nessed the misery, and often injury, caused to children, by the forcible 
administration of nauseous drugs. We should endeavour, then, to 
select such medicines as are most free from strong taste or smell ; and 
moreover try to disguise their flavour by the addition of sugar or 
syrup, children being so little select of taste, as, in general, to'deem 
that good which is sweet ; while we not only choose the most con- 
venient form, but the least bulky dose. Hence, very light powders 
(as pulvis sennse) are inconvenient for administration to children, and 
in no case should the quantity of a powder exceed ten grains. When 
very heavy or insoluble, the vehicle selected for the exhibition of a 
powder should be sufficiently thick for its suspension, when mixed 
therewith, so as to ensure the whole being swallowed. The dose of 
a liquid medicine is from a tea-spoonful or drachm, to a dessert- 
spoonful or two drachms ; a larger quantity being objectionable, in 
one dose, for an infant. 

Medicine is not required in all cases of illness in the child, altera- 
tion of diet or in the mode of management being often sufficient ; and 
in many instances the mildest medicines will suffice. This is no 
excuse, however, for giving nothing but ptisans or syrups to infants, 
and so letting them perish in acute disorders through fear of using 
adequate means. When obliged to employ active measures, it is 



GENERAL OBSERVATIONS. 



S5 



necessary to be prompt in their application, and carefully to look for 
the earliest moment when their use may be suspended and milder 
means resorted to, or the case left to the resources of nature ; which 
in infancy are so powerful when the strength is not too much broken 
by the protracted use of depletion. 

We must be attentive to support the child by suitable nourishment 
during illness ; at least it must not be left too long without some kind 
of sustenance, as the infant cannot exist many hours without food ; 
and we would solicit particular attention to this precept, neglect of 
which we have seen attended by fatal results. During febrile or 
inflammatory complaints, the diet must be restricted to barley-water, 
whey, or very thin gruel ; even the breast milk may be too stimulating, 
and will require to be mixed witli water or exchanged for lighter 
drink ; but this must be supplied at sufficiently short intervals. 
During depression or convalescence, change to a more nourishing 
food than usual will serve, to a certain degree, as a substitute for sti- 
mulant or tonic medicines ; so susceptible of excitement is the child. 

Change of air exercises the most beneficial influencein infantile 
disease, often putting an end to protracted illness in a few days. 
With the child we can avail ourselves of this measure at an earlier 
stage of acute disorders than with the adult. Being brought abroad 
or changed to another room in the same house (if more elevated and 
airy), willalmost always be useful; and we cannot be too particular 
in insisting on the apartments of a sick child being kept cool and 
airy, at least sufficiently ventilated and of an equable temperature. 
When labouring under affections of the head, however, or recently 
recovering therefrom, there is risk in too sudden exposure of the child 
to the excitement of light and air by bringing it abroad ; and danger 
in the fatigues, added to the excitement of a journey, so that we 
should prefer, in the first instance, seeking the advantages of fresh 
air, by its admission into the chamber, while light and noise were, 
at the same time, excluded ; and even after convalescence had been 
established, we should rest satisfied with merely bringing the child 
abroad, without venturing upon a journey for the sake of change of 
air, until the condition of the nervous system warranted us in 
hazarding the disturbance thus likely to be induced. Inattention to 
these considerations we have seen attended with disastrous conse- 
quences, relapses being thus brought on, or cerebral symptoms alto- 
gether induced, during recovery from merely febrile disorders. In 
some disorders of the chest, particularly in the chronic form, or when 
accompanied or induced by a spasmodic affection, the good effects of 
change of air are often most remarkable ; as in chronic bronchitis, the 
advanced stages of pertussis, and occasionally even in spasm of the 
glottis ; the beneficial influence of change of air being not less remark- 
ably manifested in lessening irritability and restoring tone to the ner- 
vous system, than in producing similar effects upon the mucous 
membranes. In all affections of the abdominal viscera this is uni- 
formly the case ; particularly in protracted forms of remittent fever, 
and in all forms of diarrhoea or dysentery. 

Climate. — In broken-down states of the system, and especially 
8 



g 6 INFANTILE THERAPEUTICS. 

in those cachectic conditions induced by or connected with strumous 
disease, not only change of air, and travelling, but change of climate, 
become absolutely essential to the restoration and preservation of 
health. A moment's reflection on the influence exercised over the 
structures of the body during growth, by the effects of the locality 
in which a child is placed ; or recollection of the direct results observ- 
able in the health from the same cause, must prepare us to expect 
most important benefits from residence in a dry, equable, and warm 
climate ; as we are so repeatedly obliged to deplore the miserable 
results of residence in situations of an opposite character. But it is 
not merely as conclusions from reasoning, however just, or principles 
however sound, that we draw these inferences ; but as the results of 
actual observations and long experience in the climates of which we 
speak — and which lead us earnestly to call the attention of the pro- 
fession, (as we find that of the public has already been directed,) to 
the great advantage of employing change of climate as a resource 
in the delicacies of childhood, without waiting for the more hope- 
less effort of employing it as a last refuge to escape from the 
delicacies of youth. Whatever form these degeneracies of health 
may assume, we know how essentially they are connected with, if 
not dependent on, tubercular formations ; and we have already 
noticed the relation of these to strumous disease. How much better, 
then, to take effectual — indeed, the only feasible — means of averting 
in childhood that tendency to degeneracy of constitution, which is 
so certain, in such cases, to manifest itself in youth, than to delay 
combating the evil until it has arrived, and we have to contend with 
some of those actual deposits of tubercular matter, which can so 
seldom be restrained — and never, perhaps, removed. 

In children so disposed — subject to glandular enlargements, and 
membranous inflammations, (whether exhibited in the form of fre- 
quent bronchial attacks, liability to croup, or gastric and intestinal 
irritation) — threatened with hydrocephalus or mesenteric disease — 
we would recommend immediate removal for the winter months to 
the more genial climates of the south of France or Italy. This re- 
moval will be seen to exercise its best results so early as three or 
four years of age — but more particularly at the ages of five or six, 
and especially seven, when, at the period of second dentition, strumous 
affections are so liable to develope themselves, or become established 
in the constitution. We have, in such climates, seen children pass 
a whole winter without one day's illness, and everyday in the open 
air, who had for more than one preceding winter been seldom out of 
the sick room, and never, perhaps, once out of doors. 

The places on the Continent best suited as winter residences for 
children are Nice or Rome ; but in the commencement of the season, 
Naples is equally eligible : and for those with whom a soft, but 
rather moist atmosphere is calculated to agree, Pau is a convenient 
place to select. Having passed a winter in all these places, we are, 
unfortunately, but too well qualified to speak of the relative merits 
of each. Rome is commonly considered the most eligible for the 
child ; and this opinion receives the high support of Sir James Clarke ; 
but as a place of common resort for delicate children, we would 



GENERAL OBSERVATIONS. 



87 



decidedly give the preference to Nice. The place to be selected in 
any particular instance, however, must depend upon the nature of 
the case ; but, as a general rule, the dry, invigorating, and even ex- 
hilarating air of Nice, (situated, as it is, on the sea-shore, and with 
its atmosphere often highly charged with electricity,) will best agree 
with the feeble frame and delicate constitution of the sick child, whose 
delicacies of health are so often connected with strumous disease. 
Where the tendency is, on the contrary, to acute inflammatory attacks, 
the nervous system excitable, and the mucous membranes disposed 
to irritability, the mild and equable temperature of Rome, little dis- 
turbed by high winds, and occasionally softened by the relaxing 
sirocco, will be found best to agree ; and if a single place is to be 
selected for both winter and spring, Rome is that to which preference 
must be given. Naples should never be persevered in, as a residence, 
on the approach of spring ; but the child be removed to Rome, or 
the still milder air of Pisa, early in February, when the keen northern 
and north-eastern winds begin to blow. The same change will be 
occasionally necessary at Nice, but not so frequently, nor then at so 
early a period — not before the middle of March. Pau is very free 
from cold spring winds, but the moistness of the atmosphere must be 
taken into account, as with strumous children, in general, it is damp- 
ness rather than cold that so much disagrees. Where passive diar- 
rhoeas exist, with a lax state of frame, or open ulcers are present, 
such a climate will disagree, and Rome, in particular, should be 
avoided, as ulcers heal ill there, and diarrhoea is liable to occur during 
the prevalence of the south wind. Nice, as a permanent residence, 
or Naples, at the commencement of winter, will best suit such cases. 
The choice of a particular house is of almost as much importance as 
the selection of the place in which to reside. Inattention to this point 
may forfeit all advantages of a change of climate. Not only must a 
good quarter of the town be chosen, and the aspect of the rooms be 
southerly, but we should be certain that the sunshine actually enters 
the apartments, unobstructed by opposing buildings or any other 
obstacle. Hence, the upper rooms of a house are often preferable to 
those lower down, as admitting the sun when the others do not. In 
sending children into the open air, great care must be taken to pro- 
tect them from the heat of the sun in spring ; and it must not be 
forgotten that the brightest sunshine is often co-existent with the 
keenest wind, when the child should not be permitted to go abroad, 
however fine looking be the day. In the management of children's 
diet, the principal point to be remarked is the necessity of diminishing 
the quantity of milk, which is not found to agree well in Italy. But 
the light and excellent bouillon, or broth, will, in part, make a good 
substitute ; and goat's milk (always easily to be had) will be found 
excellent ; the fact being, that it is the want of good pasture rather 
than any other influence of climate, which causes cow's milk so much 
to disagree in those climates.* 

* Those who have seen cows feeding on the refuse vegetables of the stalls, 
largely intermixed with orange and lemon-peel, as we have seen in Italy, will not 
be surprised if their milk is not accounted wholesome. 



g8 INFANTILE THERAPEUTICS. 

During a journey, children are liable to have their bowels out of 
order. Irregularities in diet may cause diarrhoea, and such not in- 
frequently occurs; or deposits appear in the urine, just after the 
journey is over ; but during travelling, a state of constipation is that 
which is oftenest present, and even diarrhoea, which had before 
existed, ceases. Hence, a lax state of bowels should not prevent a 
child being taken to travel ; and the constipation which may occur 
is easily mitigated by any mild aperient. But the great and important 
matter in bringing children abroad, is so to conduct the journey, as 
not to injure the children by over excitement and fatigue — in fact, 
to keep in mind, that it is for the benefit of the child, not for our own 
amusement, that we travel — a matter, forgetfulness of which has 
caused much misery in many a journey. 



II. MERCURY. 

Of medicines which act in a peculiar manner on the child, one of 
the most remarkable is mercury ; which proves, according as it is well 
or ill employed, the most useful or injurious medicine given to chil- 
dren. Mercury may be administered with impunity to the youngest 
child ; and, indeed, infants often appear to bear large doses better 
than adults ; but this by no means excuses the universal and empirical 
manner in which mercury is too commonly dealt out to children ; 
nor secures us against the evils which this abuse of so active an 
agent, is certain, sooner or later, to entail. One remarkable circum- 
stance connected with this mineral is, that mercury does not seem 
capable of salivating an infant. We have never seen it do so, nor 
are we aware of any such case being on record ; our experience, in 
this respect,coinciding with that of Dr. J. Clarke, as we have never suc- 
ceeded in salivating a child under three years of age — indeed, even 
at four and rive years old, it is not easy to do so. But we would here 
give warning, that in children after that age, at six or seven years 
and upwards, sudden and severe salivation is liable to take place, 
when mercury is given in any large dose, while the strength is broken 
down after fever, or any of the exanthems ; more especially if much 
mercury has been given (as it too often is) during the previous 
illness. This is a frightful and fatal affection, which, although it must 
be well known to practical men, has been but casually noticed by 
medical writers ; we shall, therefore, treat especially of this subject, 
under the head Cancrum Oris Mercuriale (which see). To the fre- 
quent employment of mercury hasalso been attributed thatpremature 
tendency to decay, which sometimes leads to the almost universal 
destruction of the teeth at an early age. The absence of salivation 
in the infant somewhat impedes us in the employment of mercury, 
in acute inflammations ; at least we are thus deprived of a useful crite- 
rion by which to judge of the effects of medicine on the constitution, 
and so to regulate its administration. Hence the pushing of mercury, 
so as to induce salivation in inflammatory diseases, and thus cut short 
the complaint, as we do with adults, cannot be practised with the 
young child. But mercury, notwithstanding, constitutes our chief 



MERCURY. 59 

agent in subduing inflammatory action on infantile disease, and ac- 
cordingly we find that some consider mercury as exerting a special 
influence in controlling inflammation independently of salivation. 
This influence is explained by supposing that mercury exercises a 
particular action upon the bloodvessels, or upon the blood itself, so 
as to change the condition of the one, and the constitution of the other, 
in such a manner as to interrupt or alter the morbid action going on, 
so as to prevent the effusion of coagulable lymph, or cause the 
absorption of it, and other fluids when effused, and thus obviate or 
remove structural changes ; results, which we know attend the adminis- 
tration of mercury, in whatever manner we are to attempt their expla- 
nation. However this may be, we are not to overlook the influence 
which mercury is acknowledged to exercise upon the secretions, and 
which is particularly manifested in the child ; but this, though bene- 
ficial, fall far short of a specific influence in arresting inflammation, 
and is liable to do mischief, if not cautiously resorted to. In connec- 
tion with this power, mercury has the character of quickening the 
action of other medicines, and so ensuring their effects; and hence it 
is often joined with diaphoretics, expectorants, cathartics, &c. 

It is its action on the intestinal canal, and particularly the biliary 
secretion, that is most manifest in the child ; and some give a prefer- 
ence to calomel as a purgative for infants. No mistake can be greater : 
though occasionally useful, it is at all times liable to create intestinal 
irritation, and its continued use is certain to cause it, — producing 
griping, diarrhoea, and green stools ; accompanied by fretfulness, 
feebleness, and pallor. 

This irritation, however, is sometimes resorted to in the treatment 
of cerebral affections, as a source of derivation or counter-irritation. 
On the other hand, the occasional use of a mild mercurial is service- 
able, by restoring the natural functions, when the stools are very foul 
and unnatural in appearance. 

Calomel is the preparation of mercury most frequently employed 
with the child, particularly in inflammatory affections. Blue pill is an 
inconvenient form, but useful preparation, and may be given bruised 
down in some liquid. Hydrargyrum cum creta vel magnesia are 
mild mercurials ; and from their mildness and combination with an 
antacid, are peculiarly suited to the bowels of children, when acidity 
is present, with or without diarrhoea. Calomel may be given alone 
to act on the bowels, in doses of from one-fourth to one or two grains 
at most, and usually requires to be followed, in two or three hours, 
by a dose of castor oil, or other aperient. Calomel is generally given 
in combination with other medicines, as purgatives, to quicken their 
operation ; or with ipecacuan, squill, or James' powder, as an expec- 
torant or diaphoretic. The dose is usually one-fourth or half a grain, 
or, at most, a grain or two, repeated every second or third hour. 

It is in such combinations and in such manner, that calomel is 
given in inflammatory affections, according to the seat or nature of 
the inflammation. Combined with aperients in affections of the 
head, and with expectorants or antimonials in thoracic inflammations 
and inflammatory fevers. When the intestinal mucous membrane is 
8* 



90 INFANTILE THERAPEUTICS. 

the part affected, or we fear the mercury running off by the bowels, 
an opiate (most generally Dover's powder) is added, or mercury and 
chalk selected instead. When inflammation is very acute, seated in 
an important organ, as the head or throat, or very protracted, as in 
chronic hydrocephalus, we employ in addition mercurial inunction, 
to aid the influence of the medicine on the constitution. In urgent 
cases, this must be freely had recourse to, even in infants ; for although 
the gums will not be made sore, we shall find the mouth grow hot, 
and an indication thus afforded to regulate our use of this remedy. 
From one scruple to half a drachm of the strong mercurial ointment 
may be rubbed in, twice a day, after the first year of age. 

Mercurial inunction has been recommended for the cure of infan- 
tile syphilis; but will hardly be found necessary ; neither need we 
often have recourse to calomel, for the treatment of a complaint which 
will be found almost always to yield to a mild course of hydrargyrum 
cum creta. (See Syphilis.) 

The hydrargyrum cum creta is given particularly when diarrhoea 
is present, and a mercurial indicated ; but in this case the dose must be 
small (not exeeding one grain), or combined with an opiate. Hydrar- 
gyrum cum creta alone is by no means to be taken as a cure for 
diarrhoea, as some seem to suppose ; and even when guarded by an 
opiate, any mercurial is, in certain cases, injurious. 

Mercury, in fine, constitutes one of the most powerful but danger- 
ous medicines employed in infantile therapeutics. In inflammations 
of membranous tissues with tendency to effusions of serum or lymph, 
the use of mercury, after depletion, constitutes our most efficacious 
agent of cure: particularly in inflammatory affections of the serous 
membranes, as meningitis, peritonitis, pleuritis, &:c. In ordinary 
inflammation of the mucous membrane of the air-passages it is less 
frequently required ; but in those forms in which lymph is thrown 
out, as in croup or diphtherite, the necessity for its use becomes again 
equally urgent, as also in the inflammatory affections of the stomach 
and bowels. In passive diarrhoeas and chronic dysentery, after the 
cessation of inflammatory action, mercury often proves highly irrita- 
ting or injurious ; and even in cerebral affections tending to serous 
effusion, we must discriminate between the truly inflammatory form 
and that depending on scrofulous disease, before we have recourse 
to mercury as our plan of cure. In virtue of its action on the secer- 
nent functions, particularly of the lymphatic system and the skin, 
mercury is often indicated in the child, in whom glandular and cuta- 
neous disease so often exists ; but the action which mercury exercises 
in promoting the biliary and other secretions of the chylopoietic 
viscera, is not confined to this medicine but shared in common with 
it, by several of the neutral salts and some of the vegetable purgatives ; 
while in glandular disease having a strumous origin we must use 
great circumspection in our employment of mercury. The continued 
morbid irritation of some febrile disorders and the chronic inflamma- 
tory characters of others, is perhaps best broken in upon by the use 
of mercurials ; but the abuse of these medicines in the treatment of 
all febrile attacks, as measles, scarlet fever, small-pox, &c, fee., appears 



SEDATIVES. 91 

justly to have been blamed as accelerating or inducing the develop- 
ment of scrofula, during convalescence therefrom. In confirmed 
scrofula we must be most sparing in the employment of mercury ; 
or altogether interdict its use — never, except under the most urgent 
circumstances, attempting to put the system under its influence — and 
the same is to be said of scorbutic states of the constitution, especially 
if attended by hemorrhage. 

In certain conditions of strumous disease, however, assuming the 
form of ulcerations connected with indurated glands, the alterative 
action of corrosive sublimate will be found of signal service, both 
in dispersing the glandular enlargement and disposing the ulcerations 
to heal, as we often witness in such ulcerations seated in the throat 
and fauces ; and even in the amelioration of mesenteric disease. 
Employed for this purpose, the bi-chloride must be given in very 
minute doses — not too long continued at one time, and exhibited in 
combination with sarsaparilla, which we have found decidedly more 
eligible than combination with tinctures of rhubarb or bark, as ad- 
vised by Sir Astley Cooper. Under the use of this medicine, the 
urine will be found to increase in quantity, and the stools often be- 
come of an olive-green colour. 

Underwood claims credit as being the first medical writer to re- 
commend the use of calomel in infantile disease ; and doubtless 
the medical profession is much indebted to the first introducer of so 
active a remedy ; nor should the blame of its abuse attach to him. 



III. SEDATIVES. 

Irritation is a usual attendant on infantile disease, which often 
arises directly from this source ; and in all cases, nervous suscepti- 
bility to a greater or less degree is present. Hence we are prepared 
to expect much good from the employment of sedatives, which are 
often indicated, but concerning the use of which a very general ap- 
prehension appears to prevail. This has probably arisen from the 
injurious, or even fatal results, which have followed the administra- 
tion of soothing syrups, &c, to young children by ignorant attendants. 
The ingredients of such compounds, or at least the quantity of nar- 
cotic which they contain, are seldom known ; so that their employ- 
ment, even by the regular practitioner, is dangerous, independently 
of the objection that recommending such, fosters popular prejudice 
respecting the ignorance or indifference of medical men about infan- 
tile disease. Hence the physician should a\\v&ys formally prescribe 
them ; and from no class of medicines does more signal service arise, 
when judiciously administered to the child. The evil effects of the 
habitual administration of narcotics are soon visible in infants who 
are subjected to this soothing system. The digestive organs become 
altogether deranged ; the appetite is lost or precarious ; the bowels 
are constipated and evacuations white. The body dwindles, and 
the face pale, shrunk, and sallow, with eyelids red and swollen, pre- 
sents, in its stupid aspect, an appearance not to be mistaken. When 
called upon to treat such children, it is necessary to keep in mind, 



QO INFANTILE THERAPEUTICS. 

that however injurious this practice, it is one that cannot with im- 
punity be at once discontinued, as extreme irritability of the nervous 
system, accompanied by spasm and convulsions, will follow, it the 
accustomed sedative be not gradually withdrawn. 

Opium acts with much energy and rapidity, particularly within 
the first few months after birth, and due caution must be exercised in 
prescribing it. But when once the proper dose with which to begin 
is known, and we are aware of the quickness with which it acts, and 
the length of time during which its influence lasts, we can avoid the 
danger of an over-dose, or one too frequently repeated. Conditional 
orders should always be given to suspend the medicine, while the 
child sleeps, or until the symptoms have returned. The infant fre- 
quently begins to slumber immediately on the administration of the 
first dose of the medicine, and continues to sleep for several hours, 
— the effect lasting from four to five hours, or more, at a time. 
Hence an opiate should not be renewed oftener than every third or 
fourth hour, — twice or thrice a day being in general sufficiently 
often. In some cases, however, it may be required so often as every 
hour or half-hour, until the desired result is attained, as in severe 
cholera, but its effects must in such cases be narrowly watched. 
The influence of opium is more immediate and remarkable when 
the tincture of opium, or the pulvis cretae comp. c. opio, are exhibited, 
than the syrup of white poppy, or Dover's powder, though the doses 
be equivalent. Syrup of poppy is generally preferred as the opiate 
for children ; but it is uncertain in its strength, being liable to spoil 
or be adulterated. When genuine and well-preserved, one ounce is 
considered equivalent to a grain of opium ; so that thirty drops, or 
half a tea-spoonful, would be equal to 1-16 of a grain of opium, or 
about a drop of laudanum ; this would be the dose for a child two 
or three months old. During the first month, however, we would 
not advise more than § or \ of a drop of laudanum to be given at 
once until the effect was tried, — even this minute quantity occasionally 
producing more of a narcotic effect than might be anticipated, or 
would be caused by a larger proportionate dose of syrup of poppy. 
The best and safest form for exhibiting opium to the young infant is by 
diffusing a given quantity of laudanum in a mixture with simple 
syrup, so that the dose will be always definite, however minute, as in 
the following formula, which we name the simple sedative syrup : 

No. 1. — Syrupus Sedativus Simplex. 

R. Aquae Destillatae, %\. 
Mucil. Gurn. ac. ^ss. 
Syrupi Simplicis, ^ss. 
Tincturae Opii, guttam. M. 

A tea-spoonful will be the dose, repeated every half hour till rest be 
produced ; but after the first month, double that quantity may be 
begun with. At the third month, half a drop of laudanum may be 
given for a dose, — one drop at six months old, and two after the 
first year. 



SEDATIVES. 



93 



The camphorated tincture of opium presents a preparation with 
more of sedative, and less of narcotic properties than the simple 
tincture, and also of weaker strength ; so that it may be given in 
triple the quantity, and is preferable to allay spasm and quiet irrita- 
bility, especially when connected with cough. The same may be 
said of the ammoniated tincture, which is best added to a carmina- 
tive mixture, when we want to allay pain or spasm caused by flatus ; 
the dose being double that of laudanum. 

The sedative influence of lettuce or orange-flower water would 
point them out as eligible vehicles ; but not being officinal in our 
Pharmacopoeias, they are not always to be obtained. 

Laurel water, however, can always be procured, and it is a seda- 
tive peculiarly serviceable in allaying pain, spasm, or convulsion, 
arising from intestinal irritation in the child. Hence we propose 
another sedative mixture to be called, 

No. 2. — Syrupus Sedativus Compositus. 

R. Mucil. Gum. ac. 5SS. 
Aquae purse, 3L 
Aqua? Lauro-cerasi, gtts. viii. 
Syrupi Aurantii, 5SS. 
Tincturee Opii, guttam. M. 

If we wish to obviate costiveness while employing this mixture, 
from one to two drachms of which may be given every second or 
third hour, syrup of violets may be used instead of simple syrup, or 
a drachm of rhubarb wine added. If, on the contrary, we wish to 
check diarrhoea, allay pain, or remove flatulency, — aromatics, alka- 
lies, or astringents may be combined. 

Dover's powder is a mild and safe opiate for the child, and less 
liable to disagree than perhaps any other. From i to \ a grain may 
be given at a dose, during the first three months ; and from one grain 
to two, after a year old. The compound powder of chalk with opium 
acts more energetically, and must be used with greater caution. The 
very small quantity of opium present, however, enables us to give it 
apparently more freely : from half a grain to a grain will be borne 
during the first six months, and two grains after that period, three 
times a day, or four grains by a child two years old. 

Narcotics readily produce their effect when applied to the skin of 
the child, and require proportionate caution when thus employed, 
so delicate and susceptible is the cutaneous surface. In this manner 
tincture of digitalis is often used in continental practice ; and opiate 
plasters are found most serviceable in protracted bowel complaints, 
while an English physician, Dr. Bow, extols the use of opiate frictions 
in the inflammatory affections of children. The form he employs is 
as follows; and he relates many cures effected in this way. 

No. 3. — Br. Bow's Opiate Liniment. 

B. Opii, 51. 

Saponis, £ss. 
Linim. Camph. comp. %\. 
Digere per dies aliquot et effunde linimentura. 

Sleep being almost as essential to the child as food, we can scarcely 



INFANTILE THERAPEUTICS. 

94 

foil to benefit it bv inducing a state of rest during illness, and this 
the use of opium seldom fails to do. Many alarming symptoms, as 
screaming, spasm, or convulsion, may be thus mitigated, or at once 
removed, if dependent on irritation alone. When using narcotics for J 
such a purpose, however, we should examine into the cause of irri- ; 
tation, and try to remove it, while we palliate the symptoms, — as, 1 
for example, "by dividing the gums, or freeing out the bowels, if re- 
quired ; and in inflammatory cases, depletion should always pre- 
cede or accompany the use of sedatives. After bloodletting, opium j 
appears to possess, in some instances, a distinct influence in control- 
ling inflammatory action, more especially when seated in a serous 
membrane. In cerebral irritation, or in meningitis, after depletion, 
the beneficial effects of an opiate in procuring rest and tranquillity is 
often very remarkable ; but in this case judgment and experience are 
particularly required, as cerebral irritation is very liable to pass into 
congestion in the child, and inflammation to end in effusion ; and the 
narcotic effects of an opiate would tend to obscure or aggravate the 
symptoms, and might increase the liability to congestion. The irri- 
table or spasmodic character which often belongs to the cough or 
breathing in the pulmonary affections of children, is generally miti- 
gated, and at times removed, by the use of an opiate ; and some tinc- 
ture of opium, or Dover's powder, is a useful adjunct to expectorant 
medicines, which are also better borne by the stomach when thus 
combined. 

In all cases of gastric or intestinal irritation, whether sympathetic 
or not, opium is a chief resource, and must in severe cases be admi- 
nistered in a decisive manner. An injection containing one, two, or 
three drops of laudanum, according as the child is three, six, or twelve 
months old, will often at once check a diarrhoea which has lasted long, 
and been in vain treated otherwise. 

[Too much caution cannot be inculcated upon the young practi- 
tioner in regard to the use of opium or any of its preparations in the 
case of infants and young children. Important as the remedy is, in 
many of their diseases, it is, nevertheless, apt at times to produce the 
most alarming effects, even in the minutest doses. The protracted 
use of opiates in young children has invariably a mischievous tend- 
ency. — C] 

IV. ALKALIES AND ALKALINE EARTHS. 

These exert a decided sedative influence, especially upon the 
mucous membranes, when in a state of irritation or chronic inflam- 
matory action ; while they, at the same time, alter and improve their 
secretions. Their antacid properties, in addition, render them pecu- 
liarly eligible in the treatment of infantile disease ; and we have 
often experienced their utility, more especially in controlling gastric 
or intestinal irritation. The stomach may be thus often quieted, and 
many of the more distressing attendants on diarrhoea or dysentery 
removed. They mitigate pain and spasm, appearing to restore or 
equalize the peristaltic motion. Tenesmus is often speedily removed 



CARMINATIVES. 



95 



by the use of one of these alkalies, and the character of the stools 
altered, their fetor being destroyed. In pertussis, or in spasmodic 
cough, they tend much to mitigate the severity of the symptoms ; and 
in the advanced stages of bronchitis, &c, the alkalies, in addition, 
exercise an influence over the morbid action, causing the phlegm to 
be less viscid, and consequently more easily excreted. In prescribing 
these medicines, however, we must not employ them in the early 
stages of inflammation, and we must be careful to exhibit them suffi- 
ciently diluted or guarded by some mucilaginous menstruum. Com- 
bination with opium, or its alternate use, adds much to their efficacy, 
and is frequently adopted. 

According to the object in view, will we combine, or select the 
alkali we would employ. In general, the bi-carbonates are preferable 
to the carbonates, as being less caustic ; and, for this reason, carbonate 
of soda is preferable to carbonate of potash, as well as because it is 
not deliquescent, and therefore may be given in the form of powder; 
but these objections do not apply to the bi-carbonate of potash, which 
should therefore be preferred to the carbonate, and is altogether the 
most eligible of these alkalies for ordinary use. 

When the stomach is very irritable, the liquor of potash, or lime 
water, will often answer best, or magnesia, if the bowels be confined. 
When the bowels are irritable, chalk in the form of pulvis cretae com- 
positus, with or without opium, is usually selected ; or chalk mixture 
instead. Where the stomach is at the same time irritable, however, 
carbonate of lime will not be borne; and we choose carbonate of 
soda, or, better, bi-carbonate of soda or potash. If much flatulency be 
present, with acidity, any carbonate is objectionable : the additional 
extrication of gas, caused by its decomposition, adding to the distress 
and oppression. A few drops of liquor of ammonia, or of its aro- 
matic or fetid spirit, will answer best in this case — often putting an 
end at once to the flatulency, as well as acidity, by its stimulant and 
alkaline properties. Should the action of a stimulant be objectiona- 
ble, calcined magnesia should be preferred. Liquor of potash, in 
particular, exercises an influence on the glands and skin, diminishing 
irritation and its consequences, when seated in either of these struc- 
tures, especially if connected with morbid states of the primae viae, as 
is so often the case. Enlargement of the glands of the neck, groin, 
and even mesentery, we have seen diminished under its use, when 
iodine could not be borne, or as a medicine introductory to its em- 
ployment ; and in those forms of cutaneous disease more directly con- 
nected with derangement of the digestive organs, the useful effects 
of this medicine are most remarkable. In employing this class of 
medicines, however, we must occasionally interrupt their use ; as too 
protracted a course is liable to debilitate the stomach and otherwise 
derange the digestive organs. 

V. CARMINATIVES. 

A stimulant action is often looked to as a principal agent in restor- 
ing the mucous membrane to a healthy tone. For this purpose, an 



9G INFANTILE THERAPEUTICS. 

aromatic stimulant is usually preferred, and some of the distilled 
waters, or a few drops of an aromatic oil, diffused through the mix- 
ture selected. Indeed, with some, no medicine is prescribed for a 
child, without the intervention of dill or fennel water; but this is 
objectionable, when unnecessary, as their strong odour is always 
offensive, and adds much to the disgust for medicine. To all these 
aromatic waters is attributed an antiflatulent or antispasmodic 
action ; but to some, peculiar properties are ascribed. Thus mint 
water is selected when the stomach is irritable ; but in such cases 
the simple compound infusion of mint, or fresh mint tea, is preferable. 
Cinnamon water is chosen when the bowels are the seat of irrita- 
tion. On such principles are constructed the carminative mixtures 
so commonly given to children when affected with gripings, acidity, 
flatulency, or convulsions ; and when these arise independently of 
inflammatory action, those mixtures are often of great utility. But 
we must be careful to avoid stimulants when such symptoms are 
connected with inflammation of the stomach, bowels, or any other 
organ. 

The most celebrated compound of this description is Dalby's car- 
minative, the prescription for which we give in a note ;* but some of 
the following formulas, which are more simple, will be found con- 
venient : 

No. 4. — Mistura Jlnti-emetica. 

R. Infusi Menthae, %i. 
Mucil. Gum. ac. gss. 
Syrupi Aurantii, ^ss. 
Spir. Lavandulae, c. ^ss. 
Tinct. Opii, gtts. ij. M. 
3i. — 5'J* sumat hora quaque 2da. 

In irritability of stomach with flatulency and acidity, or diarrhcea, 
when much griping or spasm is present without inflammatory action, 
the following mixture is to be employed ; to which a drachm of 
tincture of rhubarb can be added to ensure a purgative effect, if 
desired : 

No. 5. — Mistura Carminativa. 

R. Aquae Carui, gi. 

Mucil. Gum. ac. gss. 
Magnesias Carbonatis, Jss. 
Olei Cajeputi, gtts. iv. 
Syrupi Croci, ^ss. 
Spir. Ammoniae Foetid. Jss. M. 
3ss. — 3'j- sumat ter indies. 



Daily's Carminative. 

R. Aqua? Menthae Piperita?, ^ii. 
Carbonatis Magnesiae, ^ij. 
Olei Menthae, guttam 

Anisi, guttas iii. 

Tincturae Castorei, ^ss. 

Cardam. Comp. Jss. 

■ ■'■ ■ — Assafoetidae, gtts. xv. 
Spiritus Pulegii, gtts. xv. 
Tincturae Opii, guttas v. M. 



STIMULANTS. 97 

The stimulant effect of this mixture can be increased, when depres- 
sion attends, by the addition of half a drachm of compound spirit of 
lavender, or one scruple of nitrous spirit of ether, or Hoffman's ano- 
dyne liquor. In flatulent colic, half a drachm of the ammoniated 
tincture of valerian will make a preferable addition ; or four drops 
of laudanum may be added when an anodyne effect is desired. 

VI. STIMULANTS. 

Much caution is required in administering stimulants to the child, 
as excitement is easily induced, and consequently the depression 
often attendant on local disease increased, instead of being dimi- 
nished. Great mischief is thus done by the improper administration 
of stimulants to infants, to whom they are commonly given to expel 
flatus, allay pain or spasm, and throw out eruptions, or stimulate the 
child when thought to be debilitated during the progress of inflam- 
matory affections, particularly of the alimentary canal. When ex- 
hibited in such cases, all the symptoms become aggravated ; and yet 
their use is often persevered in to the last. 

We must not fall into the popular notion that the diseases of 
children arise from debility — an error of which even Sydenham 
seems to have partaken, often prescribing ammonia in infantile dis- 
ease ; but when we do find infants habituated to the use of stimu- 
lants, it will be necessary to exercise due discretion in subjecting 
them suddenly to the depressing influence of a lowering plan of 
treatment. 

When a stimulant is required, as in cases of sudden sinking or 
much depression, such as attends severe vomiting and purging, the 
volatile alkali is one of our best for children, being qujck and tran- 
sient in its action — not likely to disturb the head, or give rise to 
continued excitement, as alcoholic preparations do. Hence aromatic 
tinctures, wines, &c, should seldom be given to the infant; but the 
aromatic waters, volatile oils, or some of the milder aromatic spirits, 
may be commonly employed as vehicles or adjuncts. 

During the course of the eruptive fevers, when the eruption has 
receded, or come but scantily out, some stimulant may be required ; 
and when these fevers assume the typhoid type, stimulants must be 
employed ; but their universal use in measles, small-pox, &c, &c, as 
practised by some, cannot be too strongly reprobated. 

In dyspnoea dependent on debility and spasms, or occurring in 
the advanced stages of pulmonary catarrh, from accumulation of 
phlegm in the bronchi and inability through weakness to expel the 
same, stimulants must be employed, and the aromatic spirit, or car- 
bonate of ammonia, combined according to the circumstances of the 
case, is perhaps the best we can prescribe. 

When restlessness, spasm, or convulsions, arise from exhaustion, 
as in cases where depletion has been carried too far, or illness has 
been long protracted, a stimulant is most beneficial ; but if used as 
an antispasmodic where such symptoms arise from an opposite cause, 
as they more frequently do, an aggravation of every symptom will 
be induced. 

9 



i ' 



98 INFANTILE THERAPEUTICS. 

The following will be found a good general stimulant for the 
child: 

No. 6. — Mistura Excitans. 

R. Aquae Menthae, ^iss. 

Spir. Ammoniae arom. £ss. 
Spir. iEtheris nitrosi, gtts. xij. 
Spir. Lavandulae Comp. Ji. 
Syrupi Simplicis, ^ss. u M. 
3i. hora quaque secunda. 

Turpentine as a stimulant and antispasmodic, is peculiarly adapted 
for children — one or two drops often at once removing flatulency or 
spasm. In protracted diarrhoea, its action is most serviceable : and 
it has also anthelmintic powers, which recommend it in particular 
cases. 

The following formula will be found convenient : 

No. 7. — Mislura Terebinthinata. 

]£. Aquae Anisi, ^i. 

Mucil. Gum. ac. ^ss. 
Olei Terebinth. Rec. £ss. 
Oiei Limon. volat. gtts. iv. 
Syrupi Simplicis, ^vr. M. 

31. — 3U' h° r 3< quaque 3tia. 

VII. TONICS. 

Children often require tonics during convalescence, or in the ad- 
vanced stages of inflammatory and febrile disorders ; but they must 
be tried with caution, and used very moderately, as they are much 
more liable to induce excitement than in the adult. A principal 
object in giving tonics to the child is to restore appetite, as when 
once that is established, strength will soon be renewed by the use of 
nutritious food. For this purpose any of the simple bitters or sulphate 
of quinine, may be used. The infusions of cascarilla. columba, gen- 
tian, hop, or chamomile, diluted with equal parts of an aromatic 
water, and given in doses of two drachms or half an ounce, twice 
or thrice daily, appear to be the bitters best adapted for the child ; 
but sulphate of quinine may be looked on as a substitute for all — 
and in sufficiently small doses can be given to the youngest infant, 
as in the following formula : 

No. 8. — Mistura Corroborans* 

R. Aquae Destillatae, ^iss. 
Quinae Di-Sulphatis, gr. ij. 
Acidi Sulphur, arom. 9i. 
Tinct. Aurantii, ^ii. 
Syrupi Aurantii, Jiii. M. 

Capiat 3i« — 3'J* ter quaterve indies. 

Bark and steel are the best tonics we possess, and those most 
calculated for general use — bark is to be preferred for making a 
sudden impression in cases of urgent debility or attacks assuming a 
distinctly intermittent or periodic form ; steel for its more gradual 



TONICS. 99 

influence in protracted cases, or those merely remittent in their type. 
A combination of both will be found more serviceable than either 
singly, when debility is dependent on a cachectic state of the system, 
and spasmodic or other attacks assume a periodic form. In such 
cases, a grain of sulphate of quinine and a grain of sulphate of iron, 
dissolved (by the aid of six drops of dilute sulphuric acid) in two 
ounces of infusion of columba, (as recommended by Dr. Cheyne,) 
will be found an excellent combination, and may be given in doses 
of two drachms to half an ounce, twice or thrice a day ; or we may 
at once prescribe, in similar doses, the mistura ferri aromatica of the 
Dublin Pharmacopoeia. 

Iron and iodine are tonics of peculiar power, especially in the 
treatment of serofula, and hence, often employed in infantile medicine. 
Their efficacy in restoring appetite, when properly administered, is 
remarkable, particularly so with iron, which also possesses the pro- 
perty of improving the quality, if not of increasing the quantity of 
the blood, so as to add colour to the cheeks, while it gives strength 
to the frame ; and is altogether the best tonic we can employ in 
convalescence, after much blood has been lost during illness, or in 
cases of relaxed fibre and general debility ; in consequence of its 
astringent as well as tonic powers. Iodine is not so uniform in its 
beneficial effects upon the appetite, which it appears occasionally to 
derange rather than augment ; and this result has been estimated to 
occur in about one case out of six. When its use is too long con- 
tinued, an irritable state of the intestinal mucous membrane is liable 
to be induced, and then colicky pains, griping, or purging, with febrile 
excitement will follow ; as also if the medicine is given during the 
existence of gastric irritation ; but in such cases, its use must be 
abandoned or suspended, as must that of all tonics, when excitement 
or fever attend their administration. 

The tartrate of iron is altogether the best preparation for children, 
and that generally employed, both on account of the absence of taste, 
and the mildness of its action. In addition to its tonic properties, it 
joins a tendency to open the bowels : and this effect may be height- 
ened, and its taste quite hidden, by combination with treacle. When 
it is an object to increase the aperient aetion,this may be done to any 
extent by joining it with Rochelle Salt, or tartrate of potash. And 
if in addition, or instead, a diuretic action be desired, as in cases of 
oedema attendant on debility, we may add to the foregoing, or sub- 
stitute therefor, the bitartrate of potash. Tartrate of iron may be 
given in the form of powder, combined with an aromatic, and sugar, 
as in the following formula :* 

No. 9. — Pubis Chalybeatus. 

R. Ferri Potassio Tartratis, gr. ij gr. v. 

Pulveris Aromatici, 
Sacchari Albi, aa. gr. ij. M. 

Sumat pulverem talem ter quatcrve indies. 



* When thus prescribed, we must point out the Pharmacopceia according to 
which the preparation is made, as that of the Dublin College is so deliquescent as 
not to admit of being exhibited in this form. 



100 



INFANTILE THERAPEUTICS. 



Or a similar combination may be given in the form of bolus, and 
the dose of the tartrate carried so far as ten or twenty grains, three 
times a day, in children three or four years old, when much debili- 
tated by protracted strumous disease. In the vinum ferri of the 
Pharma'copceia, we have a similar preparation in the liquid form, 
which may be given to the youngest infant in doses of from five to 
twenty drops, twice or thrice a day ; or be carried to drachm doses, 
when given to more grown children. In a similar manner we may 
give a tincture made of acetate of iron, which is more active than 
the last preparation, but not so energetic as the muriated tincture. 
Asses milk or whey make good vehicles, and assist in disguising the 
taste ; but in cases of much relaxation, conjoined with debility, the 
muriated tincture, in doses of five or ten drops, given several times a 
day, and largely diluted, makes a most powerful chalybeate prepa- 
ration, uniting a strong astringent with a tonic power. Conjunction 
with muriate of tin or baryta adds to its efficacy in cases of scrofula, 
for which it is occasionally necessary largely to prescribe it. 

Combination with muriate of ammonia (ferrum ammoniatum) pre- 
sents the advantage of uniting the deobstruent properties of this salt 
of ammonia, with the tonic power of the muriate of iron, so as to 
temper the action of the latter, and render this compound one of the 
mildest and most useful chalybeates we can administer to the child. 
It is admissible during a state of vascular excitability, in which other 
preparations of iron would not be borne ; and is given with the best 
advantage in cases of glandular enlargements connected with ab- 
dominal obstruction, and an atonic state of the mucous membranes. 
It is well, before administering this or any other chalybeate, to get 
the secretions into a favourable state by the exhibition of suitable 
aperients ; or the ferri ammonio-chloridum may be joined with such, 
as rhubarb or taraxacum. When our object is to abate the activity 
of iron to the utmost, so as to render it least liable to heat the skin 
or confine the bowels, and thus enable us to take advantage of its 
tonic power at the earliest period after febrile or inflammatory com- 
plaints, the best combination of this kind will be made by joining 
tartrate of antimony with tartrate of iron; two parts of antimonial 
wine being added to one of iron wine, and given in scruple or half 
drachm doses, in white wine and water, three or four times a day, as 
advised by Tortual. From one to two grains of the ferrum ammo- 
niatum may be given to infants, twice or thrice a day, and double 
the quantity to children three years old. The dose of the tinctura 
ferri ammoniati is from five to thirty drops. This preparation is, in 
particular, recommended in rachitis, but there are, perhaps, good 
reasons why the phosphate of iron should, in such cases, have the 
preference. 

The carbonate of iron is a mild and efficacious preparation, re- 
sembling iron filings in action, though not possessed of equal anthel- 
mintic virtues, but more convenient for administration to the child, 
as not being attended with fetid eructations, and appearing to pos- 
sess particular efficacy in some spasmodic affections, or those accom- 
panied with periodic pains. To be useful, however, it must be 
recently precipitated, or still moist, as in the mistura ferri composita 



TOKICS. 101 

— a useful, but disagreeable form for its exhibition. The ferri car- 
bonas saccharatum of the Edinburgh Pharmacopoeia, is an eligible 
form for exhibiting this medicine to children, but must be given in 
large doses, from ten grains to half a drachm. When prescribing 
iron in the form of carbonate, it is well to add some grains of a 
bicarbonate, which will, in general, aid the objects of the medicine, 
and always help to preserve it from chemical alteration. Sulphate 
of iron, the most irritating but powerful of the chalybeate salts, ranks 
high for its anthelmintic virtues and astringent powers, checking 
secretion and excretion ; but is so liable to disorder the stomach, as 
to be unsuited for very young children ; and even for those more 
grown it should be ordered only in cases of extreme relaxation and 
debility, accompanied by profuse discharge, when its free exhibition 
will often be attended with the happiest results. The disturbance 
which iron occasionally causes to the head, is said to be best removed or 
obviated by the use of camphor, which may be given to the child 
suspended in milk : but we must keep in mind that camphor is liable 
to disagree with children, causing dyspnoea and nervous agitation. 
The best time for administering either iron or iodine is about two 
hours after a meal, when the stomach is not too full nor yet empty. 

Iodine, in the form of tincture or hydriodated solution, can be safely 
administered to the youngest child. From one to five drops of either 
preparation may be given at a dose in some sweetened water ; but 
sugar should not be added until the dose is about being taken, as 
decomposition would otherwise occur ; and distilled water alone 
should be ordered for the solution of iodine. The tincture, when 
recent, is precipitated on being added to water ; but this does not 
occur when it has been some time kept ; and it is altogether one of 
our best preparations of iodine. For external use, at all events, it is 
a milder application than the compound tincture, or hydriodated solu- 
tion in alcohol, which is now substituted for it in the London Phar- 
macopoeia. The following aqueous hydriodated solution nearly 
resembles that proposed by Lugol, and may be administered in a 
similar manner ; but the dose can be carried much farther than Lugol 
ventures, if we are only careful sufficiently to dilute the medicine^ 
and occasionally to intermit its use. Baudelocque found that irrita- 
tion of the stomach was induced when the proportion exceeded one- 
eighth of a grain of iodine, and one-fourth of a grain of hydriodate 
of potash, to an ounce of water, but with proper precautions, a grain 
of iodine, and two of the hydriodate may be given in the day to a 
child from four to seven years old, and double, or even treble these 
quantities after that age ; so that the dose of the hydriodated solution 
may be carried to half a drachm, or a drachm, twice or thrice a 
day — beginning, however, cautiously, with only a few drops at a 
time. Union with starch deprives iodine of its acrimony, (as has 
been observed by Dr. A. Buchanan,) and barley water presents us 
with a vehicle for extemporaneously effecting this compound — its 
amylaceous properties causing the immediate formation of an iodide 
of starch, indicated by change to a blue colour on the addition of 
iodine. It will be well to give warning to the attendants of this 
9* 



102 INFANTILE THERAPEUTICS. 

change of colour. To obviate, in particular, the sense of oppression 
or uneasiness of the stomach, sometimes caused by iodine, wine of 
bark is the best adjunct we can employ. 

No. 10. Solutio Iodinii Hydriodata. 

R. Aquse Destillatae, ^ij. 
Iodinii, gr. v. 
Hydriodatis Potassse, gr. x. M. § 

The combination of iodine and iron, presents particular advantages, 
and, in some of the more protracted forms of strumous cachexy, the 
administration of iodide of iron affords advantages which perhaps no 
other medicine does. Such combination may be extemporaneously 
made by adding from three to ten drops of muriated tincture of iron to 
the same quantity of the hydriodated iodine solution (as given above), 
or the compound tincture, and administering this dose in sweetened 
water, or barley water, twice or thrice a day. 

The external application of iodine is of not less importance than 
its internal administration in the dispersion of glandular enlarge- 
ments, healing of scrofulous ulcerations, and even the removal of 
unsightly scars. Ioduretted ointments are generally employed for 
this purpose, but the simple tincture is a most convenient preparation 
for general use, and may be applied to ulcerated surfaces as well as 
to the unbroken skin. It is in particular useful in those ulcerations 
within the mouth or nostrils, which often prove so intractable in 
young persons. The sense of burning heat, or pricking, which occa- 
sionally attends these applications, soon wears off ; and as the ulcer 
heals, the surface becomes altogether insensible to the irritative action 
of the medicine. 

The union of iodine with mercury presents a powerful combination, 
but we should hardly venture to order such extemporaneously when 
prescribing for a child ; for although mercurial ointment, or blue pill, 
may be joined to iodine with impunity, the presence of even a small 
portion of hydriodate of potash will create an irritating compound, 
highly dangerous either for external or internal use. It is better to 
prescribe mercurials antecedent to iodine, or to alternate their employ- 
ment ; which may often be done with advantage, as by improving 
the secretions and unloading the bowels, we prepare the system for 
the influence of the iodine. 

In cachectic states of the system, such as we often see in children 
who have been neglected or mismanaged, iodine is most useful as a 
stimulating tonic, especially if unhealthy inflammation, or ulceration, 
tending to sloughing, be present, as in pemphigus, &c. In glandular 
enlargements, which occur so generally at a young age, it is unneces- 
sary to point out the utility of iodine ; but we should keep in mind 
that children are in particular obnoxious to the evil effects of this 
medicine. For a good account of iodine, as applicable to infantile 
disease, see Dr. Ure's Practical Materia Medica, which we here refer 
to, once for all, as a valuable compendium of infantile therapeutics ; 
our own limits not allowing us to enter more minutely into the uses 
of individual medicines. 






ANTIPHLOGISTIC PLAN OF TREATMENT — BLOODLETTING. 1Q3 



VIII. ANTIPHLOGISTIC PLAN OF TREATMENT. 

The class of remedies which we shall have most occasion to use 
in the treatment of infantile disease, is that which is employed to 
combat acute inflammation : and hence called antiphlogistic. These 
remedies act principally by depletion, or as evacuants ; but we must 
not forget that a certain part of their action is stimulant, — especially 
exciting some organ or tissue, as the kidneys or skin, and so pro- 
ducing a diuretic or diaphoretic effect. This is most manifest in the 
case of cathartics, which often irritate the bowels, as well as purge, 
thus acting more or less as counter-irritants, some of their remedial 
power arising from this source. This action may, however, be 
carried too far, so as to do injury by the special irritation thus pro- 
duced, which may also prevent the expected evacuation, and aggra- 
vate, or even create, local inflammation. Much mischief arises from 
overlooking these circumstances in the treatment of children's dis- 
eases ; for in consequence of the susceptibility of their organs, this 
irritative action is peculiarly liable to be carried to an injurious 
degree. Thus it is that we see intestinal irritation induced by pur- 
gatives continued to be given to children, until nothing but a little 
bloody mucus is evacuated ; or stimulating expectorants employed, 
until expectoration has been suppressed, and a slight catarrh changed 
into a severe bronchitis. 

These errors we shall avoid by recollecting that the use of evacu- 
ant medicines is not necessarily followed by evacuation, as their 
names (purgatives, diaphoretics, &c, &c.) would imply, unless the 
necessary precautions be taken to ensure such results. These are, 
to employ only the least stimulating in the early stages of inflamma- 
tory diseases, and to premise direct depletion when required. 

IX. BLOODLETTING 

Is the first step in the antiphlogistic plan of treatment, and the most 
powerful, not only in subduing inflammation, but in ensuring the 
beneficial results of the other remedies ; most evacuants acting with 
more speed and certainty when bloodletting has been premised. In 
the child, more particularly, bleeding is required in the first stage of 
all acute inflammations. It may be practised with safety in the 
youngest infant, provided we hold in view the relation between the 
necessities of the case and the strength of the patient — the only true 
rule applicable to depletion in old or young. Repetitions of blood- 
letting are not well borne by the child. Dr. Clarke justly states 
that very young children, although they bear so well one or two full 
bleedings, but ill endure a further repetition of bloodletting, and 
hence an additional reason for its prompt employment when neces- 
sary. 

In all cases of inflammatory or febrile affections in the child, our 
first consideration should be — is it necessary to bleed ? And this 
will be necessary in all severe cases, not only for the purpose of 



104 



INFANTILE THERAPEUTICS. 



mitigating the malady and rendering it more amenable to medical 
treatment, but as our chief means of, at once, arresting the disease. 
When inflammation is seated in the substance of any organ, or in a 
serous membrane, bleeding is the more necessary — less so, if only 
a mucous membrane be affected. But the necessity again becomes 
urgent, when membranous and parenchymatous inflammations are 
united, as we see in the broncho-pneumonia of infants — a frequent 
and fatal disease of childhood, for which full bloodletting is indispen- 
sable. In croup, again, although only a mucous membrane be 
affected, the importance of the organ implicated and the peculiar 
character of the inflammation, demand prompt and free blood- 
letting ; but before deciding on this measure, we must be careful to 
distinguish between truly inflammatory croup, and those affections 
of the trachea, which originate in the extension of ulceration or 
exudation from the fauces or pharynx ; or the purely nervous affec- 
tion, denominated spasmodic croup. So in affections of the head, 
while we employ bloodletting largely in decided cerebral inflamma- 
tion, or when determination of blood to the head is clearly mani- 
fested in convulsive affections, we will be reserved in its use in the 
more ordinary cases of inflammatory action, which is of a low or 
asthenic form, such as usually occurs in scrofulous children, and 
constitutes the greater number of cases commonly denominated 
hydrocephalus ; while in cerebral irritation arising from exhaustion, 
and often seen antecedent to coma or convulsions, as well as in those 
affections when originating in the same causes, bloodletting, how- 
ever much it may seem called for to the uninitiated, must be altogether 
forbidden. In inflammatory affections of the intestinal mucous 
membrane, abstraction of blood, although necessary, is but moder- 
ately required ; but before employing this remedy we should make 
sure that inflammatory action is present, and not take every instance 
of vomiting or purging, even though accompanied with abdominal 
sensibility, for a case of gastritis or enteritis. In the febrile affec- 
tions of children when symptoms run high, a timely bleeding will 
often prove a preventive measure, by curtailing the duration of the 
fever and sparing the necessity for protracted use of other evacuants : 
thus best preserving the strength, as we have often witnessed even 
in cases of remittent fever. In the eruptive fevers, however, although 
the urgency of febrile symptoms in the first instance, or the occur- 
rence of local inflammation subsequently, may render necessary the 
abstraction of blood, this must always be done with reference to the 
necessary continuance of a disease, which, having a course to run, 
cannot be cut short ; and is liable, in its progress, to assume a typhoid 
or asthenic type. In symptomatic affections, as when the head 
becomes engaged during the existence of abdominal disease, blood- 
letting, although required, should not be carried to the same extent, 
as in a primary affection. During dentition, when so much increased 
vascular action as well as nervous sensibility is present, bleeding 
may be practised more freely than under ordinary circumstances ; 
while in scrofulous diseases, on the contrary, or in children of a 
highly strumous constitution, bloodletting should be employed with 



BLOODLETTING. 105 

the utmost reservation that the nature of the case will admit, so 
unwilling should we be to detract from the red blood circulating in 
the system. 

In the infant, or young child, we can seldom draw blood from the 
brachial veins, which are usually small and obscured by fat. We 
can generally, however, procure as much as we require from a vein 
on the dorsum of the foot, or back of the hand, or, when these fail, 
from the jugular vein. The latter might be often opened in inflam- 
mations of the head or chest, with peculiar advantage, on account of 
its vicinity to the disease; but it is sometimes difficult to stop the 
bleeding — and the employment of a bandage is here badly borne, 
especially when the respiration is affected. The brachial veins, after 
the period of first dentition, become in general sufficiently well marked 
to allow of their being readily opened, unless the child be very fat. 
Leeches, however, can always be applied, and will take a sufficiency 
of blood to answer all the purposes of general bleeding. The quan- 
tity of blood obtained by one good leech, allowed to bleed for half 
an hour, may be estimated at one ounce ; while this method has the 
advantage, from the gradual manner in which the blood flows, of 
not being liable to induce sudden collapse in young children. The 
safest place for their application is the hand or foot, as we can then 
ensure stoppage of the hemorrhage at any moment, by the use of a 
compress and bandage. When applied in other situations, as the 
cIk'M. tin . leeches have led to fatal results by a continuance 

of hemorrhage. They may. however, in affections of the head, be 
safely placed over the mastoid process, and, occasionally, in those of 
the throat or chest, over the clavicles, as we then have a firm point 
of resistance upon which to make pressure, should they continue to 
bleed. 

Great difficulty is at times experienced in commanding the hemor- 
rhage from leech-bites ; whether from the greater redundancy of 
blood in the capillary circulation of the child, the less liability of this 
fluid to coagulate, or the want of tone in the vessels consequent on 
loss of blood and preventing their contraction. However this be, fatal 
results have frequently arisen from this cause, and the physician 
should never omit giving the necessary cautions on the subject, nor 
neglect himself to see that the bleeding is arrested before quitting the 
child for the night. Indeed it is as well to avoid, if possible, ordering 
leeches to be applied to children late at night. When simple expo- 
sure to the air or compression by means of the finger and a dossil of 
lint fail in restraining the hemorrhage from the bites of leeches, which 
have been placed in a situation forbidding the use of a bandage, we 
must dust the part with some dry powder, as starch or gum arabic, 
or, if this fails, press a fine pencil of lunar caustic into the wound. 
The actual cautery may be required, as touching the bite with a red 
hot wire or knitting needle ; or we may pass a needle and silk thread 
through the sides of the wound and close it by knotting the ends 
together, as recommended by Dr. M. Hall ; or in the way employed 
in securing the vein of a horse, in which manner also the jugular 
vein can be secured when ordinary methods fail. 



106 INFANTILE THERAPEUTICS. 

Cupping is a more definite and manageable mode of abstracting 
blood than leeching, and may be practised even in young children, if 
skilfully performed. The nape of the neck, or interscapular space, 
present the best situations, being sufficiently large in surface and out 
of sight, so as to cause least alarm to the child. The quantity of 
blood to be taken must, of course, be determined by the urgency of 
the symptoms. It should be always drawn from the child in the erect 
posture, and be sufficient to make an impression upon the system — 
of which we judge best in the child by observing the colour of its lips 
and eheeks ; the former especially quickly indicate the approach of 
faintness, by the paleness which they assume, and are a much better 
guide than the state of the pulse, which is very variable. In cerebral 
affections in particular we must be guided rather by the condition of 
the vessels about the head, than the state of the pulse at the wrist, 
which may be small or appear feeble, while the carotid or temporal 
arteries are full and throbbing. As a general estimate of the absolute 
quantity to be removed at one time, we may say, that during the 
first year, from an ounce to three ounces of blood, (or the application 
of two or three leeches,) will be sufficient ; and, after the first year, 
we may usually take an additional ounce for each year of the child^s 
age, seldom having occasion within the period of childhood to exceed 
eight ounces of blood, or to apply more than twelve or at most six- 
teen leeches. We have noticed the caution necessary to be observed 
in employing repetitions of general bloodletting. The necessity for 
this will be much lessened, and the efficacy of the general bloodletting 
greatly enhanced by quickly applying leeches over the part inflamed, 
or in its near neighbourhood, so as to keep up the impression made 
on the system, and while the general circulation is yet enfeebled, 
thus directly to deplete the affected organ. A second employment 
of bloodletting, if required, should seldom be had recourse to before 
the lapse of twelve or sixteen hours ; but by this method it may often 
be avoided. Dr. Mills lays much stress on this mode of using leeches 
in affections of the head in children ; but it is a practice of general 
application, and we suppose always adopted by the judicious physi- 
cian. It must also not be forgotten that the ill-fed and enfeebled 
children of the poor will not bear bleeding to the same extent, nor 
require it so often as those of the more wealthy classes. When a 
child has been blooded too largely or too frequently, an alarming 
state of collapse may be suddenly induced, the system not possessing 
in early infancy much power of rallying from depression. In this 
state of deficient power of reaction, the child will be observed to 
become extremely pale, even the colour of the iris may change, and 
present a paler tint ; the extremities are cold, pulse feeble and fre- 
quent, breathing hurried or rattling, the respiration appearing to be 
performed almost solely by the diaphragm, and accompanied by much- 
evolution of flatus. The child becomes irritable, agitated and wakeful, 
and should depletion be persevered in, or suitable remedies (stimulants 
or sedatives) not be employed, coma or convulsions ensue ; the powers 
of life sink, and the child dies from exhaustion, passive exudation 
taking place into the- ventricles of the brain. We have seen such 



BLISTERS. 107 

cases, and Dr. Ure notices the unexpected occurrence of such symp- 
toms in children apparently strong, and to be accounted for only on 
the supposition of a peculiar idiosyncrasy, derived from a delicate 
and highly sensitive mother. At all events we should be on the 
alert immediately to arrest the bleeding when any such symptoms 
appear ; and, as a general rule, it is well to stop the flow of blood 
when decided pallor takes place without waiting for actual fainting, 
which does not readily occur in young children, and from which 
they do not quickly recover. The more ordinary and less urgent 
evils attendant on over active sanguineous depletion, are the reduc- 
tion of a child to a state of anemia, in which the strength fails, 
although the appetite may continue or increase ; the child becomes 
very fretful, wakefulness alternating with stupor ; passive diarrhoea 
is established, or more generally dropsical effusions take place. The 
buffing of the blood is not a safe guide in the child, as we have 
diseases absolutely requiring bleeding (e. g., croup, bronchitis, &c.) 
which seldom produce in the blood the appearance in question ; and 
it is even said to be more generally absent when inflammation is 
present, while it may be seen where none exists or only in a very 
slight degree. 

X. BLISTERS 

Are much employed in the treatment of inflammatory affections 
in children, and, when judiciously used, are signally efficacious ; but, 
as they induce much local and constitutional excitement, very inju- 
rious consequences follow their improper application. Hence, blisters 
should never be used in the early stages of severe inflammations, as 
a substitute for bleeding ; nor should they even follow soon after 
the employment of this remedy, unless a decided impression is made 
on the local disease and fever — otherwise, both will be aggravated 
by the effects of a blister ; and we have had occasion to order repe- 
titions of bleeding, which would not have been requisite, had not 
acute symptoms been renewed in this way. We, therefore, altogether 
reprobate the popular practice of at once applying a blister to the throat 
or chest on the first appearance of croup or cough in the child, and 
equally interdict the very early or direct application of blisters, in 
which some practitioners are fond of indulging. In croup, in par- 
ticular, when of a highly inflammatory character, blistering should 
not be attempted until the acute symptoms are subdued or have 
passed away ; and then the blister should be applied rather to the 
nape of the neck or upper part of the sternum than directly to the 
throat itself. In bronchitis or pneumonia, blisters may be used at 
an earlier period, and more directly to the seat of the malady, with 
the best effect. But it is in affections of the head that we have the 
clearest evidence of the manner in which blisters should be employed, 
for every observant practitioner must have noticed the different effects 
of a blister in the different stages of these disorders — at once aggra- 
vating all the symptoms, if applied to the scalp in the first or acute 
stage ; but mitigating them if only placed in the neighbourhood, as 
the nape of the neck — while in the advanced or last stage of the 



103 INFANTILE THERAPEUTICS. 

disorder, when coma is present, and effusion has, perhaps, taken 
place, covering the whole scalp with a blister is at times attended 
with the most marked improvement. Some attempt to obviate all 
evils, by applying blisters at some distant part (as one of the ex- 
tremities), in the first instance ; and such practice is common on the 
Continent, in the abdominal and cerebral inflammations of infants ; 
but the plan is not very efficacious, while it is accompanied by all the 
risks attendant on excess in the local irritation. We therefore prefer 
waiting until the proper time, and then applying the blister near the 
affected organ ; from which method, when judiciously employed, 
the happiest effects will often result. The application of a blister 
may often be made a substitute for bleeding in feeble children, or 
in cases of mere irritation or doubtful inflammatory character, as 
occurs in some forms of diarrhoea or cholera, convulsions or coma. 
In all cases, even of an inflammatory character, which appear clearly 
to have arisen from the suppression of an accustomed discharge, or 
long standing eruption, the use of blisters, in particular, is indicated. 
Thus obstinate convulsive attacks may, at times, be quickly removed 
by restoring the discharge from behind the ears, to which some chil- 
dren are so prone, by means of a blister, or simply by a thread smeared 
with blistering ointment ; and even diarrhoea or cholera, occurring 
during dentition, may be prevented or much benefited by a similar ap- 
plication, according to the statement of Dr. Paris, in cases where this 
eruption has not made its appearance, or has been repressed. The 
application of irritating ointments, liniments, or sinapisms, is in such 
cases particularly available, and may, in many instances, save the 
necessity for blistering. 

The application of a blister is sometimes followed by the appear- 
ance of a troublesome pustular eruption, which not only surrounds 
the blistered surface, but occasionally spreads extensively over the 
body. It is the supervention of violent local irritation in the blistered 
surface itself, however, leading to sloughing, gangrene, and death, 
that makes so serious an objection to the use of blisters with children, 
and demands so much precaution, in order to lessen the liability to 
such disaster. To effect this, we guard against the two irritating 
action of the blistering plaster, by using it of only half the ordinary 
strength; or we protect the surface by the interposition of some thin 
substance, as fine muslin, or tissue paper. In no instance is the 
blister to be left on more than a few hours (from two to four) — not 
longer, in fact, than until the skin is reddened, when vesication will 
follow ; but this result should not be waited for, as attendants always 
will do, unless the most express directions to the contrary be given. 
When the blister is removed, the part should be dressed with simple 
cerate, fresh, and spread on lint, in preference to linen, which does 
not lie so smoothly on the part. a When it is wished to continue 
counter-irritation, we prefer the employment of a succession of blis- 



- a [A much better practice is to cover the part to which the blister 
has been applied with a soft, emollient poultice. — C] 



BLISTERS. 109 

ters to keeping open the part by means of irritating ointments, as 
being less distressing and hazardous to the child, although these are 
the very reasons for which others recommend the opposite practice. 
Should the blistered surface become irritable, looking very red, and 
showing a disposition to inflame, the dressing should be changed for 
the use of some fine powder, as flour, starch, or prepared chalk. 
This should be industriously applied, so as to keep the parts con- 
stantly dry, when frequently all symptoms of irritation will disap- 
pear. Should this not occur, however, but inflammation of the sur- 
face set in, with surrounding redness, a soft poultice will be the best 
application ; or raw cotton, which is occasionally employed from the 
first, as with scalds, and from the use of which we have seen excel- 
lent results. 

According to the character of the irritated surface, however, and 
the attendant constitutional symptoms, our treatment must be guided, 
as to whether we are to employ soothing or stimulating applications, 
— or attempt the total alteration of the action on the surface, as by 
nitrate of silver. When the constitutional symptoms run high, and 
the ulcer is very irritable, we use emollient applications ; and of 
these, the following ointment, thickly spread upon lint, is that which 
we have found answer best. Its consistence prevents the necessity 
for frequent renewals, as it does not dry so quickly as the Carron oil, 
of which it may be looked on as a modification. We have seen it 
produce ease, in irritable ulcerations, when no other application 
could be borne. 

No. 11. — Unguentum Sedativum. 

R. Aquae Calcis, 

Olei Amygdal. aa. ^ss. 
Bene admisce et adde 

Adipis Preparatae, ^i. M. 

Ft. Unguentum. 

When the ulcerated surface is pale, with ash-coloured spots, and 
surrounded by a dull or livid redness, some stimulant application 
must be used, particularly if the accompanying fever assume the ty- 
phoid type (as in such case it usually does). A favourite one with 
Mr. Colles is a lotion of camphorated spirits of wine and infusion of 
chamomile flowers (3i. to the ^i.) : his mode of employing this lotion 
is to place upon the part lint wetted with it, over which another piece 
of lint is then laid, the piece next the surface not being subsequently 
removed, but kept wet from time to time with the lotion, by means 
of a sponge. We have found advantage from the fermenting poultice, 
or lotions of chloride of soda, more particularly if gangrene have set in, 
accompanied by fetid odour. An excellent mode of treating the surface 
in such instances, when it begins to slough, is to alter the action going 
on, by brushing it over with a solution of nitrate of silver (gr. x. — 9j. 
to the 3i.) and then applying a soft warm poultice, as much pain often 
attends the application. In these cases, the full employment of tonics 
and stimulants is essential to support the constitution, so as to pre- 
10 



110 



INFANTILE THERAPEUTICS. 



serve life. The child will rapidly sink, unless supplied with nutritious 
diet — broth, jelly, or arrow-root, with a little wine ; and the qui- 
nine or ammonia mixture should be freely given, according to the 
circumstances of the case. No matter how acute the original inflam- 
mation may have been, it usually all disappears when sloughing takes 
place. Such result is liable to occur, when blisters are applied (no 
matter how cautiously) to children much debilitated, or living in very- 
unwholesome situations ; and we should be slow to employ them, 
if any disposition to unhealthy ulceration has been manifested, as 
when spreading aphthse, pemphigus, &c, are present. 

In applying sinapisms to children, the powdered mustard seed 
should be mixed with an equal quantity of flour, or crumbs of bread, 
and wetted with water only. The interposition of a piece of 
gauze or fine muslin will further protect the skin if irritable ; and 
the sinapism should not be left on longer than to redden the skin, 
when it causes much heat and pain, generally in ten or twenty 
minutes. These precautions are the more necessary, when the child, 
from insensibility, cannot complain, as troublesome ulceration, or 
even sphacelus, has followed the protracted application of sinapisms. 
Judiciously employed, they are a good substitute for blisters, in those 
slighter affections arising from irritation, and in particular, when 
connected with retrocession of an exanthematous eruption. 

The other antiphlogistic remedies, like bloodletting, act principally 
as evacuants — yet not exclusively so, some special influence apper- 
taining to most of them, while several act in more ways than one, 
being Emetic, Diaphoretic, or Expectorant, according to the circum- 
stances under which they are administered. 

We shall briefly consider each class in reference to infantile medi- 
cine, the variety of drugs employed in which is not great. 

XI. EMETICS 

Are often given to the child, and are particularly serviceable in the 
first invasion of inflammatory and febrile complaints, which they 
occasionally cut short, and very generally mitigate. During the pro- 
gress of remittent or other fever, an emetic may induce crisis, or 
give a favourable turn to the complaint ; and in the exanthematous, 
in particular, when the eruption does not come kindly out, the greatest 
aid may often be derived from the administration of an emetic ; and 
the supervention of bronchitis or pneumonia, as so often occurs in 
measles, is an additional occasion for the use of emetics in this class 
of complaints. It is in bronchial inflammations, indeed, that emetics 
are so necessary with the child, for clearing out the overloaded 
bronchial tubes, as well as emptying the stomach of what may have 
been accumulated there ; children, as has been already remarked, 
being constantly in the habit of swallowing expectorated matter. 
At times they afford the only chance of relief, when suffocation 
^threatens, in consequence of the quantity of mucus secreted, as we 
often see in catarrhal fevers. The power of an emetic in thus 
mechanically freeing the air passages, is remarkably exhibited in 






EMETICS. 1 1 1 

cases of croup, where portions of false membrane have been thus 
ejected. Emetics are not to be employed when the head is much 
engaged, or any gastric affection present. We should ascertain the 
type of a prevailing epidemic, so as to avoid the use of emetics at 
the commencement of the attack, when gastritis is liable to occur. 
In some epidemics we have seen the vomiting, caused by an emetic, 
persist until death took place. When the stomach is overloaded with 
indigestible matter, as after an over-full or unwholesome meal, an 
emetic is the immediate and certain remedy; often, at once, putting 
an end to the whole train of morbid symptoms, whether exhibited 
in the form of spasm and convulsion, or the more ordinary occur- 
rences of pain, flatulency, and distension, attended by vomiting and 
constipation, or followed by diarrhoea. But it is only in the early 
stages of diarrhoea, and occasionally in colic, that emetics are admis- 
sible; as their injudicious use would only serve to complicate the 
case, by the addition of gastric irritation. In scrofulous or delicate 
children, with voracious appetite, but feeble powers of digestion, the 
tone and sensibility of the stomach may be often renewed, by the 
occasional use of a mild emetic, which not only frees the stomach 
from the accumulation of morbid secretions, but benefits the system 
at large by the stimulus thus given to exhalation and absorption, so 
aiding in the resolution of strumous deposits. The milder emetics, 
only, should be given to children, and of these, ipecacuanha is the 
chief. Tartar emetic may be administered, but is not to be chosen 
without good reason. Squill, though commonly given to infants, in 
the form of syrup, is objectionable, its operation being violent, though 
certain. Sulphate of copper has been recommended, in particular, 
to expel the false membrane in croup ; and continued in small doses, 
to prevent its formation. But no one acquainted with the disease 
would imitate the Germans in this practice ; nor does the emetic 
action of the remedy seem to possess any peculiar advantages for the 
purpose proposed. Sulphate of zinc has, with better reason, been 
selected as an emetic, in the advanced stages of hooping cough, 
when the strength is unequal to expel the viscid phlegm without the 
aid of an emetic ; and the benefit derived from sulphate of zinc is 
often so remarkable, as to make it a popular remedy of some repute. 
Ipecacuanha may be given as an emetic to the youngest infant, 
in doses of half a grain or a grain, blended with sugar, and repeated 
every quarter of an hour until it vomits ; or ipecacuan wine may be 
similarly given, in doses of twenty drops, half a tea-spoonful, or a 
tea-spoonful. After a year old, these doses may be doubled and re- 
peated at shorter intervals. On the Continent, a syrup of ipecacuan 
(containing 16 grs. to the 3i.) is used as we use ipecacuan wine; or 
an infusion made by digesting 3ij- of the root in 3iv. of boiling water, 
which may be sweetened, and given in tea-spoonfuls. Ipecacuan is 
a very certain, as well as mild emetic, and will occasionally vomit a 
child when tartar emetic has failed. In addition to its effects as an 
evacuant, ipecacuanha has the power of counteracting inordinate 
action of the bowels, while it, at the same time, acts upon the skin, 
so as to restore the equilibrium of disturbed functions. In giving 



j 12 INFANTILE THERAPEUTICS. 

tepid drinks to assist its emetic action, we should wait until vomiting 
has begun, or is threatened, otherwise we may cause the ejection of 
the emetic before the stomach has fully expelled its contents. The 
following is a good general formula for its administration: — 

No. 12. — Mistura Emelica. 

R. Aquae, %i. 

Vini Ipecac, ^ss. 
Syrupi Simplicis, ^ss. M. 

5i. — Jij. s8B P e a ^ emesem. 

Tartarised Antimony is a powerful, though not always certain 
emetic. Its action is accompanied by much depression, and evacua- 
tion by the skin or bowels constantly follows its use. Hence, it is 
preferred in severe inflammatory affections of the chest, and its use 
is afterwards continued as a contra-stimulant. Tartar emetic may 
be given in minute doses — from one-eighth to one-sixteenth of a 
grain — to young infants ; but when much depression is present, or 
the acute stage of the disorder passed, ipecacuan or squill is prefer- 
able. When gastric or intestinal irritation is present, tartar emetic 
is generally inadmissible ; and, under all circumstances, it is advisable 
to have some fluid present in the stomach, before administering this 
medicine in doses sufficient to vomit, as poisonous effects have been 
observed to follow its use, when given on an empty stomach. Hence 
the judiciousness of Professor Hamilton's advice, that the child should 
be allowed previously to suck, or be given some drink. 

No. 13. — Mistura Emetica Antimoniata. 

R. Aquae Destillatae, ^iss. 
Antimon. Tart. gr. i. 
Syrupi Simplicis, £ss. M. 

51. contains 1-16 of a grain; and from one to two or three tea- 
spoonfuls can be given every quarter of an hour till vomiting occurs. 
^ss. of ipecacuan wine, added to the foregoing, will make the action 
more certain, but less violent. The addition of squill still farther adds 
to the efficacy of the compound, as follows: — 

No. 14. — Mistura Emetica Composita. 

R. Aquae Destillatae, %'\. 
Vini Ipecacuanhas, J;ss. 
Liquor. Antimon. Tart. 3 ij. 
Syrupi Scillae, 3ij. M. 

3i« — ij. saepe ad emesem. 

Squill, though so generally given to infants as an emetic, is too 
stimulating for common use, and should never be given at first, but 
in the advanced stages of pulmonary inflammation, or when other 
emetics have failed. The syrup or oxymel of squill, in half drachm 
doses, will be certain to evacuate the stomach, when repeated suffi- 
ciently often, particularly if combined as above. We have met a 
few children that resisted the action of all emetics, and had never 
been known to vomit. 



EXPECTORANTS. 113 



XII. EXPECTORANTS. 

All the foregoing medicines act as expectorants, when given in 
small and repeated doses, or so combined as not to vomit. 

Ipecacuan is that most commonly employed with children, and 
alone often suffices to remove slight catarrh, given in doses of a 
quarter or half a grain, three or four times in the day. In severe 
attacks of bronchitis, ipecacuan alone cannot be relied on ; but after 
the use of bloodletting, or tartar emetic, when the more acute symp- 
toms have subsided, and much mucus is secreted, it is particularly 
indicated. It may be added to the tartar emetic, and given in mix- 
ture ; or in powder, united with calomel. A minute quantity of 
opium in the form of laudanum, or Dover's powder, is usually added, 
to allay the irritability of the cough, and enable the stomach to bear 
the expectorant. If the proportion of opium be too great, its effect 
is injurious, by suppressing expectoration, and checking the cough, 
so as to add to the embarrassment of the breathing. 

No. 15. — Mistura Expectorant. 

R. Aqu« Destillatae, 5L 
Mucil. Gum. ac. g 
Vim [pecacuanhe, Jij. 

Syrupi Limonuiii, JL 

r u pi Papav. Boffioif. 5i- M. 

3i. hora quique secunda. 

This may be continued at longer intervals, or given between the 
doses of the following powder : 

No. 16. — Pulvis Ipecacuanhx tt Culomelanos. 

R. Pulv. Ipecacuanha?, 

Suiunur. H vdrargyri, UL gr. x. 

Saochari albi, gr. xx. M. 

gr. i. — gr. ij. hora quaque tenia. 

One grain of this compound contains \ of a grain, each, of ipecacuan 
and calomel, and constitutes the dose until twelve months old, when 
two grains are to be given : halt' a grain or a grain of Dover's powder 
may occasionally be added. 

Calomel is thus frequently combined with ipecacuanha, and in 
severe cases its junction is essential for subduing the inflammatory 
action ; but in ordinary cases, it is unnecessary or objectionable, as 
being liable to irritate the bowels, and when this occurs to any ex- 
tent, the mercury must be suspended. 

Nothing embarrasses the treatment, or adds more to the danger of 
inflammatory affections of the lungs, than complication with gastric 
or intestinal irritation. Tartar emetic cannot then be employed ; and 
if mercury be given, it must be in very minute doses, and well 
guarded by opium. Our chief reliance in such cases must be on 
ipecacuanha, which will check the irritability in the bowels, if we 
can get it borne by the stomach. This we will be assisted in doing 
10* 



114 



INFANTILE THERAPEUTICS. 



by combination with carbonate of potash or soda, and the addition of 
an opiate The following formula? will be found serviceable in such 
cases, and also during pertussis, or spasmodic cough : 

No. 17. — Mistura Ipecacuanhas Sedativa. 

R. Aquae purse, ^iss. 

Vini Ipecacuanhas, ^iss. 
Bi-carbonatis Soda?, gr. xij. 
Syrupi Simplicis, 3U« 
Tinct. Opii, gtts. iv. M. 

Ji. — 5U- h° r a quaque 2da. 

No. 18. — Pulvis Ipecacuanhas Sedativus. 

R. Pulveris Ipecacuanha?, gr. \. 
Carbonatis Sodae siccat. gr. i. 
Pulveris Doveri, gr. ^ vel 
Pulv. Cretae Comp. c. Opio, gr. ij. M. 
Sumat pulverem talem hora quaque 3tia vel 2da. 

Tartar Emetic is a more active agent in the treatment of acute 
inflammations, and in such cases is, therefore, to be preferred, particu- 
larly in pneumonia. Our object is to get a sufficient quantity of the 
medicine borne ; and the tolerance of tartar emetic can be attained 
with the child, as well as with the adult, though not, perhaps, quickly. 
When much depression attends its use, the addition of a few drops 
of spirit of lavender, or tincture of cinnamon, will tend to obviate 
this. The following is the common form of expectorant mixture con- 
taining tartar emetic : — 

No. 19. — Mistura Expectorans JLntimoniaia. 

R. Aquae Mentha?, ^i. 
Mucil. Gum. ac. ^ss. 
Liquor. Antimon. Tart. >>i. — 3'J" 
Syrupi Limonum, 3ij. 
Tinct. Opii, gtts. ij. M. 

3>' — 3U« h° r a quaque 2da. 

In severe cases, bloodletting should precede the use of the tartar 
emetic ; in the milder forms, the latter alone will suffice ; and in feeble 
children, from whom we may fear to abstract blood, tartarized anti- 
mony will serve as a substitute ; or still better, the combination of 
this medicine, or James' powder, with calomel : by which means, 
also repetitions of bloodletting may, in many cases, be saved. 

Squill is employed as an expectorant in chronic bronchitis, &c, 
&c, particularly when the phlegm is viscid and difficult to get up, 
the febrile heat having subsided. Squill is seldom employed alone 
— when it is, twenty drops of the syrup, or ten of the vinegar of 
squill, may be given every third hour. It may be added to either of 
the expectorating mixtures already given, in the proportion of 5i. of 
the syrup, or 3ss. of the vinegar or tincture, to each ounce of the 
mixture ; or from § to i of a grain of the powder of squill added to 
each dose of the powder of calomel and ipecacuan. By combining 
squill in this manner, we can sooner have recourse to its use, and 



EXPECTORANTS. 



115 



longer continue that of the other expectorants. Combination with 
an alkali lessons the acrid qualities of squill, without depriving it of 
its expectorant power. The following mixture will be found very- 
serviceable in pertussis ; or spasmodic cough, with chronic bronchitis 
and secretion of viscid phlegm. 

No. 20. — Mutura Scillas Sedativa. 

R. Aquae Fueniculi, ^iss. 
Tincturae Scillae, 5' ss » 
Carbonatis Soda?, gr. xij. 
Syrupi Tolutani, Jij. 

Croci, 5'j* 

Tinct. Opii Camphor, ^ss. M. 

3i. — 3'j' hora quaque 3tia. 

Polygala Senega. — This is a very stimulating expectorant, and 
used only in advanced stages of pulmonary inflammation, or after 
inflammatory action has been subdued. In such cases when a dry, 
hoarse cough remains, attended by some difficulty of breathing, 
polygala will be found very serviceable ; and Eberle prefers it to 
every other expectorant in the sequelae of chronic catarrhal affec- 
tions, particularly if of a croupy character. It is very liable to 
cause purging and vomiting ; but the latter result is at times desira- 
ble, when the air tubes are much loaded, and the strength inade- 
quate to coughing up their contents. Ammonia is often added to 
the polygala in such cases, — the acetate, citrate, or carbonate being 
prescribed, as follows : — 

No. 21. — Misturx Polygalx. 

R. Decocti Polygalse Seneg. %\. 
Aquae Ammonia? Acet. ^ss. 
Syrupi Scillae, Xn, 
Syrupi Papav. Alb. 3»j« M. 

5i. — 3'J- ^ora quaque 2da. 

^ No. 22. 

R. Decocti Polygala?, ^iss. 

Carbonatis Ammoniae, gr. iv. 
Tinct. Cinnam. C. 
Syrupi Tolutani, aa. ^ij. 
Syrupi Papav. Alb. 3*j- M. 

3i. — 3'J* h° r ^ quaque 3iia. 

It is at that critical and dangerous period of catarrhal fevers (often 
so difficult to detect) when inflammation passes into debility, that 
the peculiar stimulant action of polygala, when exhibited in such 
combinations, is particularly manifested. In feeble children, the 
quantity of ammonia may be increased to double the amount above 
prescribed, and freely exhibited, until the obstructing phlegm be re- 
moved ; when the happiest results may be witnessed, children being 
thus restored to safety, when apparently at the point of suffocation. 
In less urgent cases the muriate of ammonia may be used instead of 
the carbonate in the foregoing formula, in the proportion of five or 



11(5 INFANTILE THERAPEUTICS. 

.six mains to the ounce. This salt of ammonia is a favourite remedy- 
in Germany, though so seldom employed internally by British prac- 
titioner* : we have ourselves witnessed its good effects in several 
instances. 

Polygala, in union with the other expectorants, makes a very 
powerful and celebrated compound. In free doses, it vomits strongly, 
and, as an expectorant, exercises a decided control over the more 
advanced stages of inflammation in bronchitis, croup, pertussis, &c, 
when other means have failed. Coxe's hive syrup, so famous in 
America, in such cases, is a compound of this kind ; but we prefer 
the following formula (which resembles the anti-croup mixture of 
the Parisian Hospitals), as being more easily prepared. 

No. 23. — Mistura Pulygalae Comp. 

R. Decocti Polygalae Seneg. 3iU ss ' 
Oxymel. Scillae, 3<j- 
Vini Ipecacuanhas, Jij. 
Antimonii Tartarizati, gr. i. M. 

Ten minims, to a scruple, to be given every quarter of an hour, to 
vomit ; or every hour or two, as an expectorant. A small tea- 
spoonful may be given to a child two years old. 

N o. 24. — Dr. Coxe's Hive Syrup. 
Mel Scillae Compositum of the Pharmacopoeia of the United States. 

R. Scillae, 

Polygalae Senega?, aa. ^i. 
Aqnse, foi. 
Mellis despum, Jfoss. 
Ft. Syrupus — cuique uncias cujus addatnr Antimonii Tartarizati granum. 

This acts by vomiting, purging, and sweat, the dose being from 
ten drops to one or two tea-spoonfuls. 



XIII. DIAPHORETICS 

Are not much employed in the treatment of children's disorders, nor 
do they seem to merit more extended use. Perspiration is not easily 
induced ; and the partial sweats which we witness over the head 
or abdomen, in affections of these regions, are not attended with 
benefit — rather the reverse. The intensely hot skin often attendant 
on the febrile diseases of childhood, will be best met by refrigerants 
and baths. Nitre exhibits its power in lessening febrile action re- 
markably in the child, and will be given with advantage in all such 
cases. Its combination with ipecacuanha is especially serviceable 
(from quarter to half a grain of the latter, with from two to six 
grains of the former, every third hour) ; and is better calculated to 
act on the skin than either alone — often lessening the febrile heat 
remarkably : in very acute cases, antimonial, or better, James's pow- 
der may be substituted for the ipecacuanha. Nitre may be freely 
given, in whey or barley-water, to the extent of ten grains or a 



REFRIGERANTS. 117 

scruple daily, even to young children. Should the bowels become 
irritable, the nitre must be discontinued, or guarded by combination 
with a little opium. When much heat of skin attends, this will be 
found very serviceable, even though diarrhoea be present. 

XIV. REFRIGERANTS. 

The vegetable acids are not often given to children as refrigerants, 
in consequence of the tendency to acidity and irritation of the bowels, 
so frequently present in infantile disease ; but drinks slightly acidu- 
lated with lemon juice or tartaric acid are often very serviceable. 
The latter is best given in the form of bi-tartrate of potass, as weak 
imperial, and has the advantage of increasing the flow of urine, 
while it tends to keep the bowels open ; if they are irritable, of 
course, these acids are not admissible. To boracic acid in particular 
is attributed some sedative influence which causes it to be much em- 
ployed on the Continent in the cerebral affections of infants. A 
drachm dissolved in six ounces of water, sweetened, forms the 
( Potion Calmante' of the Hopital de la Maternite : it is given in the 
dose of a tea-spoonful frequently, and may be used in preference to 
other acids ; but is not to be relied on, as it seems to be, in the treat- 
ment of the cerebral affections, at that hospital. 

The mineral acids combine a well known tonic and refrigerant 
power ; but are not as often had recourse to in the convalescence of 
children as they deserve to be. 

The best of refrigerants, however, is cold water, — and it should 
be largely given to all children labouring under febrile disease, and 
desiring cold drinks, as they usually do ; even infants at the breasts 
are much benefited by the occasional administration of a little cold 
water under such circumstances. If the stomach be very irritable, 
the water may be iced ; and in no case should children desiring cold 
drinks be denied them, as is too commonly done. Occasionally 
warm drinks are preferred : this happens usually in some form of 
bowel complaint, and has been assigned as a symptom of inflamma- 
tion of the ileum in particular. 

The influence produced upon the skin sympathetically from the 
use of cold drinks predisposes it to perspire, by lessening the action 
of the surface, and so diminishes the heat. This is an important 
part of the good thus done ; but may be directly attempted by the 
use of tepid or cold sponging, or the employment of baths. 

Sponging the surface as we do in the febrile diseases of adults, is 
not practised at all so frequently with children as it deserves to be. 
Caution is requisite in the use of these means, particularly in the 
eruptive fevers, where the employment of cold sponging, or even 
dashing, is occasionally serviceable ; but much judgment is required 
before having recourse to this measure, which should never be em- 
ployed unless the febrile symptoms run high, and power of reaction 
be undoubtedly present. The local application of cold is one of our 
most frequent and powerful means of subduing increased action. Its 
mode of employment is important : to be effectual we must use it 



US 



INFANTILE THERAPEUTICS. 



steadily, but should be careful to avoid giving the child a chill, as 
severe' bronchitis not unfrequently follows the application of wet 
cloths to the head in young children. Ice inclosed in a bladder, or a 
refrigerating mixture put therein, is the safest and best mode in 
severe cases, as acute meningitis, when the cold should be kept con- 
stantly applied — an important means not only of subduing increased 
action, but preventing serous or lymphatic effusion within the head. 
When the temperature has been completely reduced, we should in- 
termit the application of the cold, as dangerous revulsion, induration 
of the integument, or even sloughing, might be induced ; but before 
the recurrence of reaction, we must again renew the application of 
cold ; or the violence of the reaction thus induced might do more 
harm than the good we had effected in the first instance. 

Pouring a stream of cold water on the head (held over a basin, so 
that the water shall flow backwards over the head, not down the 
face), has been in particular recommended in severe cases of convul- 
sions. The employment, at the same time, of the partial hot bath, 
as a derivative, the feet or hands being immersed therein, adds much 
to the effect of this remedy. Cold applied in either of these ways, 
may require frequent repetition and long continuance ; for although 
not at any one time to be unceasingly employed, it may be necessary 
to renew its application every hour or two, night and day, for several 
days in succession, until the morbid symptoms be entirely subdued. 
The local application of cold is almost exclusively confined to the 
head, and hot fomentations alone are applied to the abdomen ; but 
the order may be reversed with advantage under certain circum- 
stances. When the cerebral symptoms are those of depression, and 
have arisen in a child much debilitated, run down by very active 
depletion or severe vomiting and purging, the application of hot 
fomentations to the head will be often found of signal service ; whereas 
cold, which is so universally used, even under such circumstances, 
only adds to the severity of the symptoms. On the contrary, in cases 
of acute abdominal inflammations, with great heat of skin over this 
region, cold lotions have been recommended, and are said to have 
produced the best results ; but popular prejudice is strong against 
such practice as yet, — and though we have occasionally employed 
them with comfort, if not benefit to the patient, in cases of gastritis, 
we have not yet had opportunity for making extensive observations 
on the subject. 

The most useful and best known of all refrigerants, however, is 
fresh cool air; and to such the child should ever be exposed when 
labouring under inflammation or fever ; not placed in a heated and 
over-crowded apartment, as is too often the case with the sick infant. 
The temperature of the chamber should not exceed 65°, and if febrile 
symptoms run high, with much heat of skin, a stream of fresh air 
may be allowed to enter directly into the apartment, from which the 
best effects result in the acute stage of exanthematous fevers, espe- 
cially small-pox and scarlatina. If these disorders are subsiding, 
however, and in particular at the period of desquamation, when the 
sensibility of the skin is morbidly exalted, care must be taken to 



BATHS. 



119 



maintain an uniform and warmer temperature, particularly in measles, 
and indeed always when pulmonary inflammation is present. 



XV. BATHS. 

The general warm bath is constantly employed with the infant to 
soothe irritation, allay pain, induce rest, and subdue febrile action. 
To effect the latter object, however, its use must be cautiously had 
recourse to ; no remedy, perhaps, is more abused than the hot bath 
with infants. A bath for a child should never be very hot, but warm, 
the temperature not exceeding 98°: 95° is a good average tempera- 
ture ; but when the object is to reduce morbid heat and retard the 
pulse, so as to relieve pain and allay spasm or nervous excitement, 
92° is the temperature that we have found most serviceable, and 
which nearly accords with the experiments of Marcus, who recom- 
mends 90° as most efficacious. In acute inflammatory affections, 
the general hot bath is altogether objectionable, causing hurried 
breathing, and exciting the circulation so as to aggravate the disease, 
particularly if seated in the respiratory organs. When the abdomen 
is the seat of the affection, it is less objectionable ; but, in all acute 
cases, the bath should be local ; and it may then be of higher tem- 
perature. When not too hot, we can leave the child for a longer 
period in the water — from ten to fifteen minutes: and its most 
beneficial effects may thus be ensured. Great care should be taken 
to dry the child perfectly, and keep it warm after being taken out. 
The use of the local hot bath, as the pediluvium, is one of our safest 
and best means for inducing derivation, or acting on the principle of 
counter-irritation, and is frequently adopted, especially in affections 
of the head. 

The forms of disease for which warm bathing is required are 
chronic inflammatory affections, particularly of the skin and abdo- 
men : and in some forms or stages of fever. In the eruptive fevers, 
especially when the brain or nervous system is much disturbed, and 
the eruption is slow to come out or has receded, a warm bath is most 
beneficial ; and in the same complaints during convalescence, when 
the skin is harsh and dry, tepid bathing contributes much to the 
comfort as well as benefit of the child. So in cutaneous disease. In 
abdominal affections of a chronic character, as peritonitis, enteritis, 
protracted diarrhoea, &c.,&c, we have seen the best effects from leaving 
children for hours together in a tepid bath, the temperature of which, 
as well as the time for remaining in, being regulated by the feelings 
of the patient. This practice is an imitation of the method so suc- 
cessfully pursued with some mineral baths on the Continent ; and 
from which we have witnessed the happiest results. Warm bathing 
is similarly recommended in chronic pulmonary affections, particularly 
pneumonia ; and its benefits are highly spoken of by some German 
writers, as Seifert, Horn, &c. — The bath is to be used frequently in 
the day, (at least twice) ; the temperature of the water varying from 
95° to 98°, that of the apartment not being below 65° ; and the child 
is to be left in the bath as long as possible. The practice is doubtless 



I oQ INFANTILE THERAPEUTICS. 

worthy of imitation ; but we have ourselves seen so much mischief 
done by the abuse of hot baths in pulmonary inflammations, that we 
confess to feeling some prejudice on the subject. While employing 
warm bathing we must keep in mind that its protracted or frequent 
use much predisposes children to take cold. Hence all due precau- 
tions must be had recourse to ; and we should watch the earliest 
opportunity for discontinuing the practice, or exchanging the use of 
the warm for that of the tepid or cool bath. 

The cold bath is a tonic of peculiar efficacy, and much employed 
with children of a delicate frame and strumous constitution, charac- 
terised by general debility and languid absorption, provided there be 
not much irritability present. Bathing in the open sea constitutes 
the best form of plunge bath, and we should have said pleasantest, 
had we not often witnessed the mode in which it is commonly ad- 
ministered — the affrighted child being plunged under water in such 
sudden and quick successions as almost to deprive it of breath : this 
practice should certainly be amended. The use of cold bathing with 
the child is to be directed on the same principles as for the adult. 
We must be careful to ascertain that there is adequate power of re- 
action present, and not persevere unless the child become ruddy and 
animated on coming out of the water ; and improve in strength and 
appetite. With very delicate children it will often be well to prepare 
them by the use of the tepid or cool bath, for the greater shock to be 
endured by a plunge in cold water or the open sea. The best time 
for sea-bathing is about noon, and the best seasons, summer or the 
early part of autumn. 

[The cold bath can under no circumstances be considered a tonic. 
Its use is especially unadapted to delicate and debilitated children ; 
it will, in fact, be productive of invigorating effects, only in those 
who have sufficient vigour of constitution to cause a prompt and 
general reaction to occur, after having been subjected to its sedative 
influence. — C] 

The shower-bath possesses particular advantages as a tonic, in 
nervous debilitated children, subject to spasmodic or convulsive 
affections, particularly where the head has been engaged ; one of 
the advantages of the shower-bath being, that the shock comes prin- 
cipally and primarily on the head (which should always be the part 
first wetted in cold bathing), and upper parts of the'body, so that 
there occurs no oppression of the breathing, nor tendency to rush of 
blood, as at times take place in ordinary bathing. The water thus 
employed, should be at first tepid or at least cool, before we try the 
full effects of cold water; and a very convenient form of shower- 
bath for a child, is the perforated tin vessel now in such general use.* 

• This vessel is thus descrihed by Dr. M. Hall, in his notes on Underwood. 
" It consists of a tin vessel, in the form of a large bottle, pierced at the bottom like 
a cullender, and terminating at the top part in a narrow tube ; when put into water, 
it becomes filled with this fluid, which is retained, by placing the finders upon the 
tube, on removing the fingers the water flows out gradually." 



BATHS. 121 

Medicated baths are employed when we wish to produce an effect 
on the cutaneous surface or the constitution, beyond what mere tem- 
perature or the mechanical action of water can impart. As such 
effects are particularly manifested in the child, while it is often incon- 
venient to bring the children to a mineral spring, or even to the sea- 
side ; it is useful to know how we may make a substitute for the 
more efficient means. With regard to thermal waters, however, it 
is as well at once to confess, that no equivalent can be supplied by 
artificial means, their peculiar efficacy arising, not from the saline 
constituents they may contain, (and which are often more insignifi- 
cant than those of common water,) but chiefly, if not solely, from the 
peculiarities of the caloric with which they are combined. 

The artificial salt-water bath, is made by adding from a quarter 
of a pound to two pounds of common salt to the bath, according as 
the age of the child varies from one to seven years. The child 
should remain from fifteen to twenty minutes in the bath, to insure 
its full effects, but if used warm, the temperature should hardly 
exceed 92°, or the bath may prove too stimulant for the skin. The 
increased stimulus thus afforded, adds much to the efficacy of the 
bath in glandular tumours ; and various forms of scrofulous cachexy, 
especially if the cutaneous circulation be languid, 

Jilkaline baths are used in nearly similar cases, when we wish to 
make a more powerful impression on the nervous system, and in 
particular, to promote secretion and absorption. Hence their utility 
in cases of spasm and convulsion, chronic cutaneous disorders of a 
strumous character, mucous discharge, mesenteric disease, &c. For 
infants, soap is a sufficiently active alkaline ingredient, but for more 
grown children, or in severe cases, the carbonates of potash or soda 
can be employed : of soap, from quarter to half a pound, will medi- 
cate a bath for a child from two to five years old; the quantity of 
soda or potash varies from three drachms to six for each gallon of 
water. 

Sulphureous baths are employed in all the foregoing cases when 
of an obstinate character, or after alkaline baths have been tried. 
In particular, they are more efficacious in some forms of cutaneous 
disease, as psoriasis and lepra ; and are highly recommended in 
some nervous affections, as chorea. Sulphuret of potash is the most 
convenient adjunct for baths, in the proportion of half a drachm to a 
! gallon of water ; but bruised sulphur infused in boiling water for 
i twelve hours, (in the proportion of half an ounce or an ounce, to a 
\ quart of water,) makes a less disagreeable and sufficiently efficacious 
bath, or lotion for infants and young children, as advised by the late 
Dr. Clarke. Iodine is the most active agent with which to medicate 
J water for baths, and that from which we receive most advantage in 
the treatment of scrofulous affections in general, and in particular, in 
some rebellious forms of cutaneous disease. From half a drachm to 
two drachms of hydriodate of potash may be dissolved in each gal- 
lon of water ; or ioduretted baths prepared according to the formula 
of Lugol, as given in the chapter on Scrofula, 
This medication of baths adds much to the efficacy of internal 
11 



| Si INFANTILE THERAPEUTICS. 

remedies, of similar indication, employed at the same time ; or renders 
equally efficacious, the administration of a lesser quantity of the 
medicine. When using stimulating substances, we must take care 
that the child's eyes are not irritated thereby ; and when employing 
sulphureous impregnations, we should protect the child from the 
annoyance of sulphuretted vapour. The quantity of water for a 
bath, according to the age of the child, may be conveniently esti- 
mated at about sixteen gallons for an infant, double that quantity at 
three years old, and forty gallons at seven. 

XVI. PURGATIVES. 

Children often require the administration of purgatives. By some, 
indeed, they are the only form of medicine given to the child ; and 
much injury is done by their protracted use, or frequent repetition. 
Were children properly managed, however, especially as to matters 
of diet, the necessity for this class of medicines would be diminished, 
and an overloaded or deranged state of the bowels be less common. 
A judicious variation of food would, in many instances, save the 
necessity for physic ; and in others, the simple warm water enema, 
or even the mere insertion of a small roll of twisted paper, dipped in 
olive oil (as nurses in their sagacity are wont to adopt) would be 
found sufficient to obviate the occasional costiveness of an infant. 

When the bowels become overloaded in the child, however, or 
their secretions deranged, much disturbance of health usually attends, 
and often severe suffering. Acidity and flatulency seldom fail to 
occur — griping and purging follow, or the bowels become consti- 
pated, and the stomach unsettled — febrile symptoms attend, usually 
of the remittent type — sleep is disturbed, and the head is liable to 
become engaged — convulsions not unfrequently arising. The judi- 
cious employment of purgatives will often remove all these symp- 
toms ; and hence their frequent utility. But similar symptoms may 
be caused, and often are, by the abuse of purgatives, so commonly 
witnessed in the treatment of children's disorders, — the stomach 
and bowels being thus irritated to an injurious degree. 

Our first object in the administration of purgatives generally is, 
to empty out the intestinal canal : and in the young infant we try 
to effect this by the mildest means. Half a drachm to a drachm of 
fresh, cold-drawn castor oil, blended with a little soft sugar, or made 
into an emulsion by the aid of mucilage of gum and an aromatic 
water, is the common dose and mode of administration. Syrup of 
violets, though seldom given in this country, is, when genuine,* an 
effectual, as well as agreeable, laxative for infants, in doses of one 
or two teaspoonfuls ; or it may be combined with castor oil, instead 
of sugar. Syrup of roses, and syrup of senna, are likewise laxative 
syrups sufficient for children. 

Castor oil has the advantage of acting with expedition, and cer- 

* Which may be known by its being changed to red by acids, and to green by 

alkalies. J 



PURGATIVES. 123 

tainty, fully freeing out the bowels ; and is hence, the laxative selected 
when we want to carry off any substances which may be lying in the 
intestines, whether old lodgements of their contents, foreign bodies 
which may have been swallowed (and often are by children) or even 
other purgatives (as calomel, scammony, &c.) which may have failed 
to act with sufficient expedition, or the action of which we wish to 
hasten and ensure. Hence, also, is castor oil so commonly given at 
the commencement of diarrhoea, when caused by improper food or 
an over-charged state of the bowels ; and even in its advanced 
stages, should scybala appear ; but we must bear in mind that this 
medicine proves highly irritating to the mucous membrane when in 
a state of excitement or inflammation (as in dysentery), and is there- 
fore not to be indiscriminately given in the bowel complaints of chil- 
dren. The dose of castor oil may be estimated at one drachm for 
each year of the child's age : but it has no effect in altering the secre- 
tions, and as the child grows older, other laxatives are required. 

Manna is the aperient now generally selected, being sweet to the 
taste and ranking next to castor oil in mildness of action, so that it may 
be administered to the youngest infant. The best flake manna 
should alone be used ; and may be given in doses of half a drachm 
to one drachm or two, in some aromatic water, so as to lessen its 
liability to cause flatulency or griping ; or combined with some other 
laxative to ensure its aperient effect. A slight demulcent and even 
diuretic action is attributed to manna, sufficiently manifest in the 
child at least, to render its selection advantageous as an addition to 
aperient mixtures, given in catarrhal and febrile attacks. 

In the following formulae, manna is prescribed alone, and in com- 
bination with other purgatives :* 

No. 25. — Mistura Mannae. 
R. Mannae optimae, £s8. 

Emulsionis Arabicae, ^ss« 
Syrupi Violse, 3u- 
Bene comraisce, cola et adde 

Aquae Mentha?, ^i. M. 

3i. — 3'J- nor ^ quaque 3tia ad effectum. 

No. 26. — 3fist. Mannae Comp. 
R. Infusi Sennae, 3L 
Aquae Menthae, ^ss. 
Mannae, 3U- 
Bene commisce, cola et adde 
Magnesiae, ^i. 
Tinct. Rhei, 3i. 
Syrupi Rosae, 3u« M. 

5i. — 3i)* nor k 3t ia quaque ad effectum catharticum. 



* The following is copied from Edwards' and Vavasseur's Nouveau Formulaire 
Pratique : 

Pastilles de Marine Tartarisee. 

R. Creme de Tartre, §ss. 

Manne, fiv. 

Eau, £x. M. 

Faites cuire jusqu' a consistanceconvenable,et faites des pastilles de 10 a 12 gr. 
Laxatif d'un usage commode pour les enfans. 



124 



INFANTILE THERAPEUTICS. 



Magnesia is often given to children, being a very mild aperient, and 
from its antacid and sedative properties peculiarly adapted for them. 
When acid is present, it acts expeditiously upon the bowels, thus 
forming an active aperient salt ; and its sedative influence is remark- 
able in cases of nervous excitement depending on intestinal irritation. 
From the prevalence of acidity and the quick action of the bowels in 
children, we need not fear the formation of concretions, as sometimes 
occurs with adults ; and Hufeland even attributes the sedative action 
of magnesia, in a great measure^ to the effect of its presence on the 
mucous membrane, acting as a protective layer to sheath the sentient 
extremities of the nerves. Mixing magnesia with the food of chil- 
dren suffering from acidity and liable to constipation, is an easy mode 
of giving medicine ; and Dr. M. Hall's suggestion is good, to add the 
magnesia to the last meal at night, to be worked off in the morning 
by an enema, if necessary. It is generally given in combination 
with other purgatives, and blended with syrup of roses, or combined 
with manna, (as in the foregoing formula,) magnesia constitutes an 
efficient aperient for common use. The dose varies from a few 
grains to half a scruple for infants and children of two or three years 
old, after which a scruple to half a drachm will be required twice or 
thrice a day. 

The neutral salts furnish us with a class of aperients particularly 
serviceable in the febrile and inflammatory affections of children. Of 
mild and easy operation, they not only serve powerfully to deplete 
the system, but do so in a manner similar to that commonly adopted 
by Nature herself in freeing children from disease — namely, by 
causing copious secretion from the intestinal glands and mucous mem- 
brane. In this respect their action is so remarkable as to answer, in 
many instances, instead of the more specific action of mercury, the 
use of which may thus be frequently spared, even where the liver is 
implicated. The saline aperients best adapted to children are tartrate 
of potash and sulphate of magnesia. Tartarized soda, as a more 
energetic salt, is, in severer cases, necessary, and sulphate of potash 
has some properties which have long made it a favourite medicine in 
the treatment of children's complaints. Sulphate of soda we seldom 
or never prescribe for a child. It is the most liable to irritate the 
mucous membrane, causing exhausting watery stools, without carry- 
ing away solid contents : but we must always keep in mind while 
using saline purges, that numerous liquid stools may follow without 
the bowels being once emptied out. 

Whichever of these salts we employ, it should be freely diluted 
both to protect the mucous membrane from irritation and to promote' 
the purgative action. The latter object will be best and most con- 
veniently attained by giving the child some bland diluting liquid a 
short time after the salt has been swallowed — while we select thin 
barley water or weak chicken broth as the best vehicles in which to 
administer the medicine ; and salts are always less liable to disagree 
when the fluid in which they are taken is swallowed warm. 

Phosphate of Soda may, from its purely saline taste,' be thus 
administered in broth or gruel, without the child being conscious of 
taking medicine ; the quantity sufficient to move the bowels bein* 



PURGATIVES. 125 

little more than what is required to impart an agreeable saline taste. 
We have found this a most convenient aperient in cases of delicate 
fretful children. But tartrate of potash (soluble tartar) is at once 
the mildest and most efficient saline aperient that can be employed 
in febrile and inflammatory affections of children. It is that which 
we most frequently prescribe, being quick in operation and acting 
extensively over the intestinal canal ; while it not only does not 
gripe, itself, but lessens this tendency in other purgatives, as scam- 
mony and senna, when combined with them. The dose of these 
aperient salts varies from one scruple to half a drachm, given every 
two or three hours, until it operates. The tartrate of potash and 
soda (Rochelle salt) is a more energetic aperient, possessed of little 
disagreeable taste ; but fit only for older children. It is the salt 
most usually added to the infusion of senna ; and is the best suited 
to join with tartar emetic, when we require to exhibit a powerful, 
depressing evacuant, i?i acute inflammatory and febrile cases. Sul- 
phate of magnesia we have found particularly serviceable when the 
stomach was irritable, or colicky pains present. We have been 
enabled to open the bowels easily by a solution of ihe pure sulphate 
of magnesia in mint tea (infusion of fresh mint), when all other 
medicine was rejected. The addition of lemon peel hides the nause- 
ous taste of Epsom salts, as also union with the bitartrate of potash. 
Hence the common refrigerant drink called imperial (and made by 
dissolving one drachm of cream of tartar in a pint of boiling water, 
sweetened and flavoured with lemon peel), constitutes an elegant 
vehicle for exhibiting sulphate of magnesia to children — a combina- 
tion which appears to have, in addition, the advantage of restoring 
tone to the stomach, while it removes constipation, as has been justly 
noticed by Dunglison. The addition of a bitter prevents the tendency 
which a long or frequent use of saline purges has to debilitate the 
digestive organs — but no compound for this purpose is so efficacious 
as that of dilute sulphuric acid with sulphate of magnesia, exhibited 
in the well-known compound, infusion of roses ; from which we 
have derived the most signal advantage in the treatment of those 
cases of constipation with relaxed mucous membrane, so common in 
children, and so often accompanied by prolapsus ani. 

Sulphate of potash is more persistent in its action, and its continued 
use more directly influences the glandular secretions into the intes- 
tines. Hence, though seldom given alone, it is much used in com- 
bination with rhubarb ; and this compound (or rather the compound 
of rhubarb with sal polychrest) constituted the favourite remedy of 
the older English practitioners, particularly Fordyce, in the treat- 
ment of disordered bowels in children, especially when connected 
with mesenteric disease. When more active purgatives are required, 
or one exercising a wider range of action, by exciting the muscular 
fibres, and causing fecal evacuations rather than watery discharges, 
rhubarb is that generally chosen, being at once certain and safe, so 
that it may be given to the youngest children. Rhubarb has a tonic 
and astringent action as well as aperient, which strengthens the 
stomach, while the bowels are kept free ; so that not only are the 
11* 



126 INFANTILE THERAPEUTICS. 

digestive organs improved by its use, but a general alterative action 
apparently exercised upon the constitution. Hence has rhubarb 
Ion- held "its repute as a valuable aperient in most of the delicacies 
of childhood. From three to five grains taken every morning, or 
one or two drachms of the infusion, continued for some time, with 
occasional intermissions, tend to restore tone to the stomach and 
bowels, so often in a relaxed and irritable condition in children oi a 
strumous habit or inclined to mesenteric disease ; but rhubarb is 
seldom given alone. Its combinations constitute our best and most 
manageable purgatives in infantile practice. 

Rhubarb acts most powerfully when given in powder ; but the 
infusion (Ed. Pharm.) is sufficiently active for the child, and perhaps 
more convenient, as the taste can be thus better disguised. Cinna- 
mon has this tendency, and should therefore be selected as the aro- 
matic with rhubarb. Any of the neutral purgative salts may be 
combined with infusion of rhubarb. Rochelle salt, or soluble tartar, 
are preferred ; and magnesia (which corrects the tendency that 
rhubarb has to gripe) is a favourite combination for children, either 
in this form or in powder : 

No. 27. — Pulv. Rhei & Magnesia*. 

R. Pulv. Rhei, 9i. 

Magnesiae calcinatse, 9ij. 

Pulv. Cinnamomi, gr. x. M. 

In doses of three or four grains, every third hour, to a child of six 
months — six or ten grains will be required after twelve months 
old ; and occasionally even much larger doses. 

An elegant substitute for the above formula, and which may be 
considered as equivalent to Gregory's powder, in a liquid form, can 
be made by triturating finely powdered rhubarb, for a few minutes, 
with " fluid magnesia," straining the liquor, and adding a little syrup 
of ginger.* A drachm of coarsely powdered rhubarb macerated in 
three ounces of Brandishe's alkaline solution, also furnishes an excel- 
lent preparation, at once more tonic and aperient than the simple 
infusion. These combinations of rhubarb with an alkali, particu- 
larly when improved by the addition of a bitter, as calumba, consti- 
tute a valuable association of medicines of extensive utility in that 
large class of disorders incident to childhood, in which faulty diges- 
tion and slow bowels are joined with general delicacy of constitution. 

Sulphate of potash forms the most common combination with 
rhubarb, and so joined they act even more directly than the neutral 
salts alone upon the liver and other intestinal glands, so as to afford 
an efficient substitute for mercury, in altering their secretions. 

We subjoin a formula for the exhibition of rhubarb with bi-sulphate 

* See remarks on some uses of Sir James Murray's " Fluid Magnesia," published 
b}* Mr. Donovan, in the fourth vol. of the Medical Press. 

The profession are much indebted to Sir James Murray for the introduction of 
so important an acquisition to the Materia Medica, as the Fluid Magnesia — a pre- 
paration particularly available in the treatment of children's complaints. 



PURGATIVES. 127 

of potash, which from its acidity tends to disguise the taste ; but being 
deliquescent cannot be given with rhubarb in the form of powder : 

No. 28. — Infusum Rhti Salinum. 

R. Infusi Rhei, .^iss. 

Bisulphatis Potassse, 5 SS - 
Tinct. Cinnam. ^ss. 
Syrupi Sennae, 5iv. M. 

5i. — 3'J- h° r k quaque 3tia. 

Rhubarb is the medicine generally selected as a purgative at the 
commencement of diarrhoea, or during its progress ; whenever, in 
fact, we wish to leave the bowels with a tendency to remain quiet, 
after having been acted upon. Hydrargyrum cumcreta is generally 
combined with it under these circumstances, especially if the biliary 
secretion be much deranged. The addition of half a grain, or a grain 
of Dover's powder, or double the quantity of Pulv. cretae comp. cum 
opio, renders the operation of the aperient milder; and, indeed, may 
be often added with advantage to any purgative for the child, when 
we apprehend griping, or that the bowels are irritable. The astrin- 
gent property of rhubarb is increased by toasting the root before 
pulverising it. 

No. 29. — Pulvis lihti Cumpositus. 

R. Pulveris Rhei, ^\. 

Hydrargyri. c cretS, pr. x. 

Pulveris Aromatici, gr. v. M. 

gr. iij. — gr. v. bora quuque 3lia. 

Calomel may be used instead of hydrargyrum cum creta, but half 
the quantity will suffice ; and if an opiate be then added, it should be 
Dover's powder, not powder of chalk and opium. 

Sen)ui is a prompt cathartic but liable to gripe, it produces a decided, 
though not violent impression on the system, and may be used instead 
of rhubarb, or in conjunction with it. Senna does not exercise the 
same salutary influence on the digestive organs, however, but is more 
efficient in febrile and inflammatory complaints, particularly when 
the bowels are loaded with mucus. It is usually given in combina- 
tion with some of the neutral salts, as well to correct its tendency to 
gripe, as to exalt its efficacy as an aperient. 

Infusion of senna when prescribed for children, should not be 
ordered of more than half the ordinary strength ; or it should be 
diluted by an equal quantity of some aromatic water, of which 
pimento is to be preferred as best hiding the taste. Tincture of 
orange peel and other bitters, have a similar effect, and may, in 
general, be added. Baudelocque suggests a convenient way of de- 
priving senna of all medicinal appearance, and giving it as drink, by 
preparing coffee with an infusion of senna, made by pouring the re- 
quired quantity of cold water on one drachm of senna leaves over 
night. To this we are in the habit of adding as much liquorice as 
will impart sufficient sweetness. The powder of senna is inconve- 
nient from its bulk, but the compound powder, containing scammony, 



128 INFANTILE THERAPEUTICS. 

may be occasionally prescribed with advantage, in doses of gr. iij. to 
gr. vi. every third hour, when the bowels are difficult to move. Syrup 
of senna is a good laxative, and convenient adjunct in 5ss. or 3i. 
doses ; but the manna is liable to separate on its being kept, which 
could be avoided by ordering treacle, instead of sugar, in making 
it up. 

No. 30. — Mlstura Sennas, 

R. Infu&i Sennae, 

Aquae Pimentae, aa. ^i. 

Tartrat. Potassae, 5ij« 

Tincturae Corticis Aurant. %[. M. 

5i. — 3'J* k° r ^ <i u aq ue sua. 

Jalap is an active purgative, but not very certain. When the 
liver or stomach is deranged, it is liable to disagree, causing vomiting, 
griping, &c, &c. ; but from its wide range of action along the middle 
tract of the intestinal canal, quickening the peristaltic action, while 
it excites the serous secretions, it is very serviceable with children, as 
it well clears out the bowels, when overloaded ; and is hence the 
best purgative we can select for emptying the intestinal canal, in 
those cases of illness, brought on by surfeit or over feeding. Toasting 
jalap lessens its liability to cause vomiting and colicky pains ; while 
the addition of some drops of oil of lemon, and trituration with sugar, 
removes the nauseous taste. The watery extract is, from its mild- 
ness, well suited to children; but the pure resin triturated with almonds 
and sugar into the form of emulsion, or dissolved in spirit and blended 
with syrup, (as recommended by Dr. Coxe,) purges even in small 
doses, plentifully, with little disturbance. Jalap may be combined 
with any of the other purgatives ; but ipecacuan is a very beneficial 
adjunct, as it adds to the purgative power of the jalap, without losing 
its own peculiar action. Such a combination is especially suitable 
when we want a purge during the existence of inflammation of the 
chest. Calomel quickens the action, and is often added. From two 
to five grains of jalap may be added to each dose of the powder of 
ipecacuan and calomel,, already prescribed : or the folio wine formula 
adopted;* & 

No. 31. — Pulvis Jalapas et Ipeeacuanhz. 
R. Pulveris Jalapae, 3ss. 

■ Ipecacuanhas, gr. v. 

Submur. Hydrarg. gr v. 
Sacchari albi, gr. x. M. 

gr. ij — v. hora quaque 3tia. 

When our object is to produce serous discharges from the bowels 
and so to keep up depletion, jalap, in combination with Lme slline 

taini^ja^Mnof «& f tS ^W "iSSrh ^"f ^^ t P Q ^^e biscuits, con- 
S Jalap , and may be taken once or twice a-day, according to the effect." 



PURGATIVES. 129 

purge, is generally chosen ; and crystals of tartar, as in the compound 
powder of jalap, is one of the best, and is often required in the treat- 
ment of children's complaints, particularly when of a dropsical 
character. 

When in addition to serous discharges we wish to act energetically 
upon the bowels, so as to move them when constipated, or produce 
counter-irritation (the head being engaged), we generally have re- 
course to scammony. 

Scammony is a most energetic purgative, but liable to gripe and 
irritate the mucous membrane highly : hence care must be taken in 
the mode of prescribing and combining it. When given in powder 
it must be reduced to the minutest state of division, and an aromatic 
always combined : the addition of a neutral salt, or alkali, is parti- 
cularly advantageous. Scammony, though so liable to disagree, is 
often required in the treatment of children's complaints, when the 
bowels are difficult to move, or loaded with mucus, which prevents 
the action of other purgatives, but which scammony in particular 
seems to possess the power of removing ; hence its utility in obstinate 
constipation, the removal of worms, &c., &c. 

No. 32. — Pubis Scammonii cum Cretd. 

R. Pulveris Scammonii, 3ss. 

Cretae prepar. gr. xv. 

Aromatici, gr. v. M. 

gr. ij. — gr. v. hora quaque 3tia. 

One of the most effectual and yet mild purgatives that we are ac- 
quainted with, is a combination of rhubarb, scammony, and sulphate 
of potash, in equal parts, to which an aromatic may be added. 

No. 33 Pulvis Scammonii et JRhei. 

R. Pulveris Rhei, 

Scammonii, 

Crystal. Sulphatis Potass®, aa. gr. x. 

Optime tere simul et adde 

Pulveris Aromatici, gr. v. M. 

gr. iij. ad gr. vi. hora quaque tertia. ad effectum catharticum. 

The " Huile Purgative" of Swediaur is a mild yet active form, for 
exhibiting scammony, and is conveniently given to children in emul- 
sion, according to his formula, as follows : — 

No. 34. 

R. Scammonii, ^i. 

Olei Amygdalarum, Ji, 
Solve calori3 mitioris ope et adde 

Emulsionis Arabicae, ^i. M. 

5i. — 5"* h° rd> °i u aq u e tertia. 

Aloes is not often given to the young child, from the bitterness of 
its taste, and its liability to gripe : however, there is no purgative 
that, if judiciously employed, is more useful. It combines a tonic, 
as well as purgative power, in virtue of its bitterness : it has a par- 
ticular relation to the liver, either as a substitute for bile, when defi- 



130 INFANTILE THERAPEUTICS. 

cient, or as passing through the liver, and so causing its flow ; and it 
is well known, from its action on the rectum, to be peculiarly hostile 
to ascarides. The taste of aloes is well hidden by combination with 
extract of liquorice, and perhaps there are few medicines to the taste 
of which children sooner become reconciled : of its various prepara- 
tions, the compound decoction, and the vinum aloes, are those best 
fitted for administration to the child. 

No. 35. — Mistura Mdetica^ 

R. Decocti Aloes Compositi, giss. 

Extracti Glycirrhizse, ^ij. M. 

gi £ii. bis terve indies. 

In cases where the head threatens to be engaged, without inflam- 
matory action being present, particularly in children of a leucophleg- 
matic habit or lethargic tendency, this mixture, as a derivative 
purgative, is the best we can employ — as also- when we wish to 
expel ascarides. Its anthelmintic powers will be much enhanced 
by the addition of half a drachm or a drachm of the muriated tincture 
of iron, which also corrects the tendency to regeneration of worms. 
Aloes, when used as an anthelmintic, may be employed in the form 
of suppository or ointment. The following suppository is recom- 
mended by Swediaur ; and the ointment is used in the German hos- 
pitals by rubbing a small portion round the navel,, in cases of colic,, 
connected with worms* 

No. 36. — Suppositorium Anthelminticum. 

K. Pulveris Aloes, gss. 
Muriatis Sodse, ^U]. 
Farinse, ^'ij. 

Mellis,.q*. s. ut ft. massa. M. 

Instar nucis, in forma suppositorii, utendum. 

No. 37. — Unguentum Jnthelminticum. 

R. Pulveris Aloes, 2i. 

Extracti Fellis Bovini, SJij. 
Unguenti Simplicis, §i. Mv 

Ft. unguentum. 

When the bowels are obstinately costive, purgative enemata must 
be had recourse to : care is required, however, in administering them 
to the child, as mechanical injury has been caused by their use. 
The tube is to be introduced cautiously, inclining its direction slightly 
towards the left side, while we soothe the child whose cries or struggles 
would so much impede the operation ; the fluid is to be injected 
slowly, or at intervals, so as gradually to distend the bowels, and 
thus penetrate far up the intestines, without causing too great or 
sudden distention thereof. In children the intestinal tube readily 
dilates, and if over-distended soon loses its contractility ; the more 
so the younger the child, so that great inconvenience or even danger 
may arise from over-distention caused by injection of too large or 



ACCIDENTS AND DISEASES AT BIRTH. 131 

too frequently repeated enemata; as Guersent has justly pointed out, 
and as we have seen. Four ounces of fluid are the most that should 
be administered to an infant, and not more than six ounces, until 
after five years of age, nor is it necessary that an enema should 
exceed eight ounces during the period of infancy. The following is 
a good general formula : 

No. 38. — Enema Purgans. 

R. Decocti Hordei, ^v. 
Muriatis Sodae, Qu. 
Olei Olivarum, 3 v. M. 

A drachm or two of spirits of turpentine may be added, if much 
flatulency be present. The cautious introduction of the tube far up 
the bowel so as to allow the flatus to escape is an important measure 
of relief in such cases ; the distress thus caused at times amounting 
to such a degree as to threaten suffocation. We have occasionally 
been able to confer great benefit in preventing the accumulation of 
flatus, by allowing the ivory pipe (detached from the tube) to remain 
in the anus. 



CHAPTER VI. 

ACCIDENTS AND DISEASES OCCURRING AT THE PERIOD OF BIRTH, OR 
SHORTLY AFTERWARDS. 

The infant at birth may labour under certain morbid conditions, 
or it may suffer from accidents or diseases either peculiar to the first 
moments of existence, or materially modified by the circumstances 
belonging to that period. These are usually first noticed by the ac- 
coucheur,and require to be considered se/?«ra^e/y, in a system of child's 
medicine, both on account of the great danger attending many of 
them, and also of the peculiarities which remove them from under 
the rules applicable to diseases of the same name in the general prac- 
tice of medicine and surgery. 

Of the importance of these affections of early infancy, we may 
judge from the great improvement that takes place in the probability 
of life after the season for their occurrence has gone by. Thus, 
according to the Northampton Tables, we find that out of 1000 per- 
sons born at the same time, the probability is, that 257, or more than 
one-fourth, will be dead at the close of the first year ; while of the 
remaining 743, but 118, or less than one-sixth, will be dead at the 
close of the second year.* The Annual Reports of the Registrar 
General of births, deaths, and marriages also show that of the deaths, 
at various ages, registered in England and Wales, during the two 

* Macculloch's Dictionary of Commerce. 



ACCIDENTS AND DISEASES AT BIRTH. 
I o -■ 

rears ending June 30, 1839, 216-29 per 1000 (more than a fifth) 
IcZZlmderUvel^ months of age; while only 126-6 per 1000 
(about an eighth) occurred between the first and second years 

In the present chapter we shall include notices of a number of 
those ailments which are not susceptible of nosological arrangement, 
havino- no connexion with each other except their occurrence at the 
same early period of life ; and we propose, in doing so, to limit our 
observations to peculiarities belonging to that period, and, as far as 
possible, to avoid occupying our pages with discussions upon general 
principles of medicine, when these require no variation to suit them 
to the case in hand. 

I. STILL-BORN CHILDREN (ASPHYXIA NEONATORUM). 

Children are occasionally born in a state of asphyxia, and without 
active interference upon the part of their attendants, would be cer- 
tainly lost. The causes of this state are natural feebleness of consti- 
tution, existing to such an extent as to render the infant incapable of 
spontaneously making the muscular exertion necessary for the com- 
mencement of respiration,— or similar incapacity produced by long 
continued pressure upon the brain, — or interruption of the foetal cir- 
culation by compression of the funis, before respiration has been esta- 
blished. 'To these causes, Dr. Edward Jorg, in his ingenious essay 
on the foetal lungs, has added the circumstance of a too rapid and 
-easy delivery, which fails to produce such a degree of compression 
of the placenta, and obstruction to the foetal circulation, as he sup- 
poses to be requisite for making the system feel the necessity of respi- 
ration.* 

The state of asphyxia may exist in a greater or lesser degree ; the 
child may be completely still-born, with no indication of life except, 
perhaps, the pulsation of the funis, or a feeble action of the heart : 
or it may make ineffectual efforts at breathing, or even cry faintly, 
and yet subsequently perish, from want of strength to establish per- 
fectly the process of respiration. Under all these circumstances a 
good deal can often be effected by art : and we are encouraged to 
persevere in efforts at restoring animation, both by experience, and 
by reasoning upon the fact that the less heat an animal produces, the 
longer it can exist under a condition of asphyxia. We have already 
seen,! that the heat of the new-born child is about 3° less than that 
of the adult ; and hence we have an explanation of what experience 
proves, — viz., that it can exist longer without respiration. In every 
instance, therefore, in which we have not positive evidence of the 
child's being dead, in the existence of putrefaction, or such malfor- 
mation as is incompatible with life, we should give a fair trial to the 
means of restoring suspended animation, presently to be spoken of. 
What length of time is sufficient for a fair trial cannot be exactly 

* Die Fcetuslunge im Gebornen Kinde, &c, von Ed. Jorg. Grimma, 1S35. 
f See p. 32. 



STILL-BORN CHILDREN. 133 

specified, as it must depend upon the degree of asphyxia, and upon 
the progressive success attending our efforts. As long as the slightest 
attempt at motion of the respiratory organs is evinced, or the least 
pulsation of the heart continues, we have good grounds for persever- 
ing, in the hope of ultimate success, and we shall, probably, be stimu- 
lated to a longer continuance of our exertions, if we recollect that 
cases are upon record, in which infants have been resuscitated even 
after having been buried in the earth for several hours.* A remarka- 
ble instance of this tenacity of life once fell under our own observa- 
tion in the case of an immature child, which, having come into the 
world by the process of spontaneous evolution, underwent so much 
compression as produced complete asphyxia. As the child retained 
no signs of vitality, it was placed in a corner of the apartment, with- 
out being separated from the placenta, (which was expelled along 
with it,) and allowed to remain exposed to the cold air for nearly 
an hour, when, upon an accidental examination, the heart was found 
to beat feebly, and proper means being employed, resuscitation was 
effected, and life prolonged for twenty-four hours. 

The treatment of still-born infants must be, in some degree, regu- 
lated by the cause of the asphyxia which, as we have already stated, 
varies in different cases, and is accordingly attended with different 
symptoms. Thus we may have the naturally feeble infant, with 
pallid face and lips ; open and flaccid mouth ; relaxed limbs ; and 
cord pulseless, or beating feebly ; or we may have the full, large, and, 
as it were, plethoric child, in which the face is swollen, and purple, 
and the cord tense and pulsating strongly ; indicating the presence 
of a condition somewhat approaching to that of apoplexy. These 
two conditions are, by some, denominated, respectively, asthenic and 
sthenic, and will, of course, require some variation of treatment; 
but, in either variety, our first object should be to remove every 
obstruction to the passage of air into the lungs. For this purpose, 
we place the child with the mouth uncovered, and pass our finger 
into the fauces, for the purpose of removing any mucus or other 
matter which may obstruct the access of air, and also to tickle those 
parts, and thereby excite respiratory movements. With the latter 
object in view, we should also rub and gently slap the chest, and 
expose it, for a short time, to the stimulating operation of the cold 
air. If these means do not succeed, we must further stimulate the 
thorax, and soles of the feet, by friction with spirits, and irritate the 
nostrils and fauces with a feather dipped in the latter ; or by holding 
hartshorn, or carbonate of ammonia to the nose. 

The foregoing steps are proper in both forms of asphyxia, and 
may be taken before dividing the funis, which should not generally 
be done, as long as it continues to pulsate, unless respiration be fully 
established. If the child's face be livid and swollen, indicating con- 
gestion within the head, and marking the case as belonging to the 
sthenic species, it will be well to endeavour to relieve the circulation 
by dividing the cord, and allowing some blood to escape from the 

* Johannes Bohn de renunciatione vulnerum, &c. Lipsiae, 1755. 
12 



134 ACCIDENTS AND DISEASES AT BIRTH. 

umbilical vessels, before applying a ligature. If the blood flows 
freely, it shows that circulation is still active, and is an additional 
reason for perseverance. Should the funicular circulation have been 
obstructed before birth, or cease shortly afterwards, it will be most 
convenient to divide the cord at once, as we shall then have the 
management of the child more within our power, for th<3 application 
of other means of resuscitation of which we are about to speak. 

Two practices are invariably adopted with still-born children, 
after the separation of the funis — viz., inflation of the lungs, and 
the warm bath. These, when used with judgment, are unquestion- 
ably means of great power in exciting respiratory action — but when 
injudiciously employed or persevered in, we have no doubt, they 
frequently become agents of destruction. It is now well ascertained 
that there is no more certain and speedy means of destroying ani- 
mals, than a brisk insufflation of air into the trachea ; and therefore 
it is positively wrong to use any powerful mechanical means for this 
purpose, in the new-born child. The gentle filling of the lungs with 
air does, however, frequently excite respiratory movements, and also 
facilitates pulmonary circulation, and should therefore be cautiously 
practised. In doing it, no trachea pipe or bellows should, we think, 
be employed ; but air simply blown into the mouth — the operator 
applying his own lips (with a bit of silk or muslin intervening for 
the sake of cleanliness) to those of the child. While doing this the 
head of the child is to be slightly drawn backwards ; its nostrils must 
be held between the finger and thumb of one hand, and the fingers 
of the other should be placed upon the pit of the stomach, so as to 
prevent the air from passing into that organ. When the chest has 
been distended, it may be compressed gently with the hand, so as 
again to empty it, and the inflation may be repeated three or four 
times, or until the commencement of natural respiration is announced 
by a sneeze or deep sigh. In addition to the evil consequences 
likely to attend upon the force that would be exerted by bellows or 
other apparatus for inflation, we may mention that insufflation of cold 
air, in the event of resuscitation, seldom fails to produce dangerous 
bronchitis ;* a fact, the -knowledge of which furnishes an additional 
reason for employing the air that has been previously warmed in 
our own lungs. The disadvantage of using air already deteriorated 
by having been respired is more than counterbalanced" by the other 
advantages of this plan. 

With respect to the warm bath, those who have frequently wit- 
nessed its employment with still-born children will recollect that 
when it does good it is at the first moment of its application : imme- 
diately upon plunging the child into it, respiration may be set agoing, 
and a cry uttered — but if this does not occur at once, keeping the 
child longer immersed in the water will seldom prove successful. 
This is explained by the discoveries of Dr. Edwards,! who found 
that the lower the natural or artificial temperature of an animal may 

* See Dublin Practice of Midwifery, p. 239. 
f Op. cit. p. 283. 



DEFORMITIES— IMPERFORATE ANUS. I35 

be, the longer it can exist in a state of asphyxia ; but that, at the 
same time, the momentary application of heat, as well as of cold, 
acts as a stimulus, and produces more forcible motions. Conse- 
quently, he says, " the immersion of a great part of the body in warm 
water, is frequently an efficacious means of reanimating a child 
just born without signs of life. As soon as motion is produced, or if 
it be slow in manifesting itself, it will be right to abandon a method 
the prolonged use of which would be fatal." The object, then, is to 
plunge the infant quickly into a bath hot enough to stimulate it 
(probably about 100°) ; and if respiratory motions be produced, to 
withdraw it, and continue the excitement of the surface by friction 
with dry, warm flannel ; and when respiration is well established, 
to lay it in a warm bed. A prolonged immersion in warm water 
would have the effect of raising the temperature of the child, so as 
to render it less capable of enduring the state of asphyxia, and would 
also prevent access of air to the surface of its body, which is known 
to possess a powerfully vivifying influence. We may, sometimes, 
especially in the sthenic form of asphyxia (when the child's face is 
red and swollen), advantageously combine the stimulating action of 
cold with that of heat; by dashing the head with cold water while 
the lower part of the body is immersed in the warm bath. The same 
rule applies to this plan as to the simple use of the warm bath; it must 
not be persisted in if not immediately successful. 

The researches of Dr. Edward Jorg, published in his work already 
quoted, show that our care for the establishment of perfect respiration 
is not to cease when we get the child to breathe so well as to enable 
it to live for days, or even weeks. It may survive so long and yet 
die from the effects of an imperfect filling of its lungs with air. Many 
cases of cyanosis, infantile bronchitis, atrophy, and even convulsions 
owe their origin to a partial continuance of the lungs in their foetal 
condition — a state to which Dr. Jorg has given the name of atelec- 
tasis pulmonum. Should the child, therefore, continue to breathe 
feebly, and show an inability to suck, after animation has been 
restored, we must endeavour to promote more perfect respiration by 
friction on the surface, and stimulate the intestines by an aperient of 
castor oil ; or, if there be much mucus obstructing the bronchi, it may 
be advisable to excite vomiting by administering half a drachm of 
ipecacuan wine. 

It is useless to speak of the employment of tobacco fumes, electri- 
city, or enemata, as recommended by some writers in the treatment 
of still-born children : for the two latter there is no time, and the 
former is now deservedly expunged from the list of means of restoring 
suspended animation. 

* 

II. DEFORMITIES IMPERFORATE ANUS. 

Several varieties of this morbid condition are to be met with. The 
anus may be simply closed by skin, or a membranous septum, at the 
termination of the rectum ; or the rectum may terminate in a cul-de- 
sac, at a greater or lesser distance from the natural situation of the 



j n 6 ACCIDENTS AND DISEASES AT BIRTH. 

anus • or the amis may appear perfect, but an obstruction exist in 
the gut, at some distance within it. In other cases we have known 
the "rectum to terminate by opening into the vagina ; or bladder in 
the male subject. When there is no anus, the case is usually disco- 
vered early, and time given for deciding upon the steps necessary 
to be taken ; but when the opening appears perfect, and the obstruc- 
tion exists at some distance within it, we do not become aware of the 
circumstance until it is observed that no discharges can be procured 
from the bowels ; or, perhaps, until a vomiting of meconium takes 
place. As soon as our attention is called to the matter, in such a case, 
we must institute a careful examination of the anus by means of a 
probe or flexible bougie, and be guided in further steps by the result of 
the investigation. The only relief that can be given will, of course, be 
by an operation ; and the exact nature of this must depend upon the 
particular circumstances. If the anus be merely closed by skin, or 
a membrane, all we have to do is to make a sufficient incision 
with a bistoury, and prevent closure of the opening by the use of 
tents. If there be no vestige of the rectum, an attempt must be made 
to reach it by incisions with the scalpel ; and if there be an obstruction 
in the gut at some distance from its external opening, its removal 
must be aimed at with the bistoury or trocar. By some it has been 
recommended to make an artificial anus in the groin in cases in 
which the gut cannot be found. The operation would be a very 
hopeless one ; but a consideration of its merits, and of the exact modes 
of performing the other operations, belongs rather to the province of 
the surgeon, than of the child's physician — who, in that capacity, 
has merely to ascertain the nature of the deformity, and must draw 
upon his own general knowledge of surgery, or apply to another 
practitioner for the means of its removal.* 

III. IMPERFORATE VAGINA. 

The labia occasionally cohere at birth, and sometimes the vagina 
opens into the rectum, or terminates in a cul-de sac. Unless the 
closure of the labia interferes with the opening of the urethra, nothing 
is required, or proper to be done, during infancy, and the case belongs 
to the general practice of surgery. If the urethra be obstructed, which 
seldom happens, we must have the obstruction removed in whatever 
way may suit the individual case. 

IV. IMPERFORATE PENIS. 

Deformities of various kinds occur in the urinary organs of the 
male. The urethra may be altogether deficient, in which case there 

* In a paper lately read before the French Academy of Sciences by M. Amussat, 
a successful case of operation for imperforate rectum is detailed in which the safe 
establishment of the artificial anus is attributed by M. A. to the drawing down of 
the intesline, and securing of its mucous membrane by sutures, to the skin, so as 
to prevent the infiltration of fecal matter between the extremity of the rectum and 
the wound in the integuments. In these almost hopeless cases, every hint is of 
value. — Gazette Medicate, torn. 3. [Note to 2d Edition.] 



SPINA BIFIDA. 137 

is usually concurrent deformity in the bladder: the anterior wall and 
corresponding portion of abdominal integuments being deficient, and 
the mucous membrane, with the mouths of the ureters, protruded 
through the opening. Examples of this deformity are to be seen in 
every museum, but are, of course, beyond the reach of remedial art. 
In other cases, the urethra is not carried through the glans, but ter- 
minates by an opening behind that body, on the under surface of the 
penis. This variety, which receives the name of hypospadias, is also 
irremediable, and is seldom of any importance during childhood, as 
the urine will usually find its way through the irregular passage. 
Sometimes, but rarely, the orifice of the urethra, or of the prepuce, 
will be found imperforate, and will require treatment. In the latter 
case, the operation of circumcision may as well be performed at once, 
and will remove all difficulty. In the former, the natural opening 
must be rendered pervious, if necessary, by a cutting instrument, and 
kept so by the regular introduction of a small bougie. 

Retention, or rather sujjpression of urine, may, and often does, 
occur in infants, without the existence of any malformation or disease 
whatsoever. We are often told, for example, twenty-four hours after 
birth, that no urine has been voided. In such cases, we should care- 
fully examine the parts concerned to ascertain if any physical obstruc- 
tion exists, and also feel the lower part of the abdomen to learn if 
the bladder be distended. If it be, and that the external openings 
are free, we may introduce a probe or small bougie into the urethra 
for the purpose of removing any mucus, which might block up its 
canal. We do not recollect having ever found it necessary to intro- 
duce a catheter. Most usually the stoppage of urine is owing to its 
non-secretion ; and this may obtain for many hours after birth, with- 
out any evil consequences. All we need to do is to place the infant, 
for a few minutes, in a warm hip-bath, and leave the rest of the 
treatment to nature.* Many deformities of the urinary and genital 
organs occur in both males and females, and are now and then 
dragged into a disgusting notoriety as instances of hermaphroditism. 
As these, however, have no practical bearings upon our subject, we 
shall not at present delay to notice them. 

V. SPINA BIFIDA. 

By this term is designated a malformation of some part of the 
vertebral column, in which the spinous processes are deficient, and 
the contents of the spinal canal protruded in the form of a round, 
compressible tumour, containing fluid. In some instances this tumour 
is covered with integument; in others, it is divested of this, and pre- 
sents a reddish fungous appearance. The place of its occurrence is 
most commonly in the lumbar vertebrae ; but it may exist in any 

* A curious case of retention of urine and diseased bladder, in a new-born infant, 
dependent upon an encysted tumour in the pelvis, will be found in the 2d volume 
of the Medical Press, p. 386, related by Dr. Peebles of Dublin. [Note to 3d Edi- 
tion.] 

12* 



13 § ACCIDENTS AND DISEASES AT BIRTH. 

other part of the column, or in the sacrum. The size of the tumour 
varies from the bulk of a nut to that of the closed fist \ or it may be 
even larger: at birth it is usually flat, owing to the compression 
which it undergoes while passing through the vagina, but shortly 
afterwards it is protruded by the passage of fluid from the spinal 
canal into its cavity, and is then in some instances semitransparent. 
A paralytic or deformed state of the lower extremities frequently, but 
not constantly, coexists with spina bifida. In some cases the fluid 
can be forced out of the tumour, back into the canal, and the margin 
of the bony opening felt through the integuments ; but pressure of this 
kind will usually produce convulsions. In a case which we lately saw, 
the integuments appeared as if cut by a sharp instrument round the 
base of the tumour, which was itself quite destitute of skin, and pre- 
sented a reddish appearance, resembling the fungus which we occa- 
sionally see occupying the situation of the brain in, what is termed, 
an acephalous fostus. The prognosis in spina bifida is very unfavour- 
able — the tumour commonly sloughing and bursting soon after 
birth, and occasioning immediate death : or the child perishing early 
in convulsions. Instances, however, are upon record in which the 
patients have lived for months, and even years ; and Sir A. Cooper has 
published two cases, in which he effected what may be termed 
cures.* The plan which he adopted was, in one case, the continued 
employment of pressure by means of a concave mould of plaster of 
Paris, lined with lint, and held on by a roller, until at length the 
tumour could be altogether reduced within the spinal canal, when 
the opening was permanently protected by a suitable truss. In the 
other instance, repeated punctures with a needle were made at inter- 
vals in the tumour, and the fluid drawn off, pressure being in the 
meanwhile applied by means of a piece of pasteboard and a roller. 
By these means adhesive inflammation was excited in the coverings, 
and the opening thereby permanently closed. More recently M. 
Dubourg has related two cases in which he effected perfect cures by 
amputation of the tumour and subsequent application of the twisted 
suture, so as to bring the edges of the divided skin into apposition. 
In the performance of the operation, M. D. attaches much importance 
to the preventing, so far as is possible, the escape of the spinal fluid, 
or the entry of air into the spinal canal.t 

In managing these cases shortly after birth, our chief object should 
be to protect the tumour from any pressure or irritation, which might 
occasion inflammation and gangrene, as instant death is to be dreaded 
from bursting of the sac. At a subsequent period we may cautiously 
try pressure ; or if that cannot be borne without producing convul- 
sions, repeated punctures with a needle, as practised by Sir A. Cooper, 
may be attempted, — and the bulk, perhaps, by that means reduced 
so much as to admit of a truss being applied. 

Spina bifida is occasionally complicated with hydrocephalus, and 
sometimes tumours of a nature precisely similar to it are met with 

* Med. Chir. Trans, vol. ii. 

| See Gazette Medicate, also Medical Press, vol. vi., p. 117. 



TONGUE-TIED — HARE-LIP. 1 3 9 

upon the head — the fluid passing out, in a sac of dura- mater, through 
an opening in one of the cranial bones. The same principles of 
treatment apply to these affections as to actual spina bifida. 



VI. SHORT FRENUM LINGU2E (TONGUE-TIED). 

The frenum linguae is sometimes so short, or its attachment to the 
tongue extended so near to the tip, as to interfere with the motions 
of the organ in sucking or speaking. Nothing is more common than 
to have infants brought to us, alleged to be tongue-tied, and yet the 
existence of the malformation, to an extent requiring artificial aid, is 
extremely rare. If the tip can be protruded beyond the lips, nothing 
need be done, as sufficient motion will then be permitted to allow of 
sucking, and the frenum will gradually lengthen as the tongue comes 
to be more employed. The division of the frenum should, therefore, 
not be wantonly performed, especially as it is not altogether unat- 
tended with danger — instances having occurred of serious hemor- 
rhage ; and even of suffocation from a turning back of the loosened 
tongue to such an extent as to impede the access of air into the 
glottis.* When interference is absolutely necessary, a very slight 
nick with a sharp scissors is all that will be required. The mode of 
operating is, to place the two fore-fingers of the left hand under the 
tongue, on each side of the frenum, and to raise it as much as possi- 
ble from the floor of the mouth ; then with the scissors in the right 
hand to divide the edge of the frenum, taking care to direct the points 
downwards, so as to avoid injuring the ranine arteries. The child 
must be watched for a little, lest hemorrhage should occur ; and it is 
to be recollected that the blood may pass down into the stomach, 
arid a considerable quantity be lost without the issue of any from the 
mouth. 



VII. HARE-LIP. 

The consideration and treatment of this deformity belongs to the 
surgeon — all that the child's physician, as such, has to do with it, is 
to consider when the operation should be performed. If the child 
can suck, it is better not to submit it to the hazards of an operation 
in early infancy. But cases occasionally occur in which such a 
degree of deformity exists as to demand immediate assistance, in order 
to give the infant a chance of life. The nature of the operation, and 
modes of performing it, belong altogether to the province of surgery. 

We occasionally meet with a child born with one or more teeth, 
which may require to be extracted in order to prevent injury to the 
nurse's nipple : but if they be not productive of the latter effect, it is 
wiser not to meddle with them, as by extraction, we may do perma- 
nent injury to the rudiments of the second tooth, which is buried in the 
gum beneath that which we remove. 



* Petit, Mem. de l'Academie des Sciences. 



14 ACCIDENTS AND DISEASES AT BIRTH. 



VIII. DEFORMED FEET. 

Three varieties of deformity of the feet are to be met with. These 
are termed — valgi, when the foot is turned outwards; vari, when 
it is turned inwards ; and pes equinus, when the toes are pointed 
downwards, the foot being extended so as to cause it to approach a 
right line, with the leg. The immediate cause of these deformities 
appears generally to exist not so much in the bones, as in the muscles 
which influence the motions of the foot — •. any alterations observable 
in the former, in old cases, being probably often consecutive. Delpecji 
found that, upon dividing the tendo-Achillis in young persons who 
had died subject to one of these deformities, it became easy to restore 
the foot to its natural position, no trace of deformity remaining. Ac- 
cordingly, he inferred that the primary alteration is a shortening of 
the gastrocnemii and other extensor muscles, and that the distortion 
primarily produced is the pes equinus, or extended foot : that subse- 
quently the varus, or turning of the foot inwards, is easily induced, 
because the posterior extremity of the os calcis is naturally inclined a 
little in that direction, and the distortion is favoured by the ordinary 
action of the gastrocnemii upon that bone, tending to bring the foot 
somewhat inwards. As the turning inwards increases, the plantar 
muscles, ligaments, and aponeurosis, are gradually contracting ; and 
the deformity becomes greater, until first the external margin, and 
subsequently the dorsum of the foot, comes to be the part resting 
upon the ground. 

The valgus, or turning of the foot outwards, so as to make a resting 
place of the inner margin, is not so common as the other deformities. 
It is produced by a shortening or inordinate contraction of the mus- 
cles situated on the anterior and external surface of the leg, whose 
office is to rotate the foot outwards. 

The remote cause of these deformities, M. Delpech refers to an 
original defect in the nerves supplying the limb, in consequence of 
which there is a want of balance in the development and action of the 
antagonist muscles. His view is borne out by a fact which we have 
already stated, viz., that spina bifida, which, of course, must often 
involve a lesion of those nerves while in the spinal canal, is fre- 
quently complicated with deformed feet. 

The treatment of deformed feet must be based, in principle, upon 
the view we have taken of the immediate cause. Our object must 
be gradually to extend the muscles, whose shortness or inordinate 
contraction produces the distortion ; and as far as possible to encou- 
rage the action of their antagonists. The first object is to be attained 
by mechanical contrivances, in the nature of shoes, adapted to the 
foot in such a way as to tend gradually to bring it into its natural 
position. The form of shoe required will vary according to the kind 
and degree of distortion, and its construction must depend upon the 
ingenuity of the surgeon and the instrument-maker.* The principle 

* For a description of an excellent form of shoe for vari, see Professor Colles's 
valuable paper in the first volume of the Dublin Hospital Reports. 



NiEVI MATERNI. 14l 

of its application should be to make the extending force very gradual, 
and to apply it so as to act upon the shortened muscles : particular 
care should be paid to the prevention of any injurious pressure upon 
the part which is made the point d'appui. The action of the anta- 
gonist muscles should be encouraged by friction, and by daily moving 
the foot in the directions in which these muscles would naturally 
act. 

The period most favourable for the removal of all these deformities 
is early infancy, the parts being then most flexible and susceptible 
of alteration in position, and the patient most easily managed. In 
more advanced life, the rigidity of the muscles is so great, as usually 
to frustrate any attempts at elongating them ; and under these circum- 
stances; M. Delpech has recommended, and successfully practised a 
division of the tendo-Achillis. Our business, however, as child's 
physician, is to recommend the early employment of curative means ; 
and if these be properly adopted upon the principles just suggested, 
there will, probably, be no occasion for any more violent expedients.* 

Supernumerary toes and fingers will sometimes be met with in 
an infant, and perhaps so situated and attached as to make their 
removal desirable. We should not, however, recommend an opera- 
tion for that purpose in early infancy. The child is then little able 
to endure the shock of any operation, however slight ; and as this is 
not a necessary one, it will be better to defer it for a few months. 



IX. NiEVI MATERNI. 

The new-born child may labour under a variety of organic mal- 
formations in the texture of the skin, all of which are classed under 
the name of nssvi, although they differ very materially from each 
other, both in degree and nature. The most common forms of naevus 
are the brownish mole, and the claret stain. These are frequently 
met with upon all parts of the body, and vary very much in size. 
They appear to be simple discolorations of the skin, occasioned by an 
alteration in the structure of the rete mucosum. They are not much 
elevated above the rest of the surface : and as they commonly remain 
stationary during life, without causing any injury except from their 
unsightliness, it is better not to meddle with them. We know of no 
means whereby they can be removed without the danger of leaving 
a greater deformity in their stead, and therefore think it wiser not to 
interfere. t All these marks are attributed, but without any good 

* For full information respecting these deformities, we may refer to L'Ortho- 
morphie, par J. Delpech, Paris, 1828 ; to Professor Jbrg's Ueber Klumpfiisse und 
eine leichte u. zweckmassige Heilart derselben, Leipzig, 1806; and also to Pro- 
fessor Scarpa's Memoire sur la torsion congenitale des pieds des enfans, &c, tra- 
duit per J. B. F. Leveille, Paris, 1804. 

[We may also direct our readers to the 1st, 2d, and 3d vols, of the Medical Press, 
passim, for several interesting disquisitions upon Delpech's operation, to which, 
attention has been recently re-directed by M. Strohmeyer. [Note to 3d Edition.] 

f Dr. Frankel, in his German translation of this work, mentions a proposal for 
the treatment of this form of naevus, which was communicated by Dr. Paulli of 



142 ACCIDENTS AND DISEASES AT BIRTH. 

foundation, to effects produced upon the mother's imagination during 
pregnancy, and accordingly they are usually likened, by the aid of 
an active 'fancy, to objects for which she has longed, or by which she 
has been frightened, as fruits of various kinds, mice, spiders, or other 
disgusting animals. 

Other nsevi exhibit a more important alteration of structure, being 
raised in granulated tumours above the skin, and consisting of a con- 
geries of vessels, sometimes venous and sometimes arterial, imbedded 
in a sort of parenchymatous tissue, and often identical in their nature 
with the disease termed ( aneurism by anastomosis.' The colour 
and external characters of these tumours vary considerably, — being 
sometimes dark-blue, or livid ; in other instances of a vermilion 
hue — occasionally raised on a neck or pedicle, and again growing 
from a broad base. Their size and situation are also very various — 
not being always confined to the skin, but appearing at times in the 
tongue, lips, labia pudendi, &c. A particular disposition to their 
formation appears to exist in some individuals, and we have seen so 
many as sixteen upon the body of a young child. Some nasvi, like 
simple moles, remain stationary during life, and do no injury ; others 
show a constant tendency to enlarge, which is much stimulated by 
any trifling irritation, as a bruise, scratch, or slight pressure. Any 
circumstance which quickens the circulation, as anger, warm 
weather, or active exercise, may increase their bulk and heighten 
their colour, by producing a greater determination of blood to the 
surface ; and the skin covering them being usually very thin, they 
frequently burst, and may occasion alarming, or even fatal, hemor- 
rhages. 

When nsevi are small in size ; in situations unlikely to suffer from 
pressure ; and show no tendency to enlarge, they call for no treat- 
ment ; but .when opposite conditions exist, surgical aid is required, 
and must often be had recourse to even in very young infants.* The 
principles upon which this aid is to be afforded are threefold. 

Their growth may be restrained by the continued application of 
cold washes, and the gentle pressure of a bandage ; or inflammation 
may be excited in them by various means ; or lastly, they may be 
extirpated by the knife or ligature. The first-named plan has the 
sanction of Mr. Abernethy's recommendation ; but still can scarcely 
be looked upon as more than palliative, and, so far as the bandage 
is concerned, is inapplicable to many cases of the disease, both on 
account of local situation, and of the likelihood of severe irritation 
being occasioned by pressure. 

Landau to the Meeting of German Naturalists and Physicians, held at Stuttgart in 
1834. Dr. P.'s plan consists in tattooing the naevus with needles and a while pig- 
ment, in a manner similar to that adopted by the South Sea Islanders, and often by 
sailors of our own country. Dr. Frankel states that Dr. Paulli succeeded in this 
operation in several instances. The tattooing must be proceeded with gradually, 
and caution observed not to make the punctures too deep. We are not aware of 
the nature of the pigment used. [Note to 4th Edition.] 

* For a case of extirpation of a nsevus six hours after birth, by Mr. Balby, see 
Med. Chir. Review, vol. viii., p. 204. 



RUPTURES. 



143 



For the production of inflammation, various means have been 
devised : caustics of different kinds were applied by the old surgeons, 
and by producing ulceration, occasionally destroyed the disease. But 
this practice was often followed by considerable irritation, and some- 
times by dangerous hemorrhages, and is now in a great degree laid 
aside. It was, however, in some measure consonant with the plans 
of nature, as we have seen many cases of large naevi in which ulcer- 
ation set in spontaneously, and the whole disease was removed, 
leaving a healthy cicatrix. Latterly it has been recommended by 
Mr. Hodgson, of Birmingham, to vaccinate naevi; and in some in- 
stances, this plan has been productive of good effects. It has also 
been proposed by Dr. M. Hall to pass a couching needle into the 
centre of the tumour, and by moving it from side to side, to break 
down the vascular network of which it is composed; by repeating 
this process at intervals of a month or six weeks, he has found a 
gradual diminution to be occasioned. In other instances a seton has 
been drawn through the nsevus for the purpose of exciting inflamma- 
tion ; a modification of which plan, viz., to pass twelve or fourteen 
threads through it at different points has been recommended by Mr. 
Adams of this city, and has been found to answer very well. 

Where every part of the disease can be removed by the knife, it 
is, perhaps, the least severe plan, and likely to be attended by the 
slightest mark ; but if it cannot all be taken away, there is consider- 
able danger of hemorrhage, and of a further growth of the tumour. 
Ligatures have been employed in several ways, viz., by applying a 
single ligature round the tumour, where that was practicable ; or, by 
passing a double thread through its substance, and tying the tumour 
m two portions ; or, what we believe to be a very useful plan, by 
passing five or six common sewing needles through the skin surround- 
ing the naevus,and bringing out the points (also through the skin) on 
the opposite side, so as to make the needles cross each other in the 
form of a star, and then winding a ligature tightly under them in the 
same manner as is done in the operation for hare-lip, or in securing 
the vein of a horse after bleeding. By these means an artificial 
pedicle is formed for the naevus, and sufficient pressure may be ap- 
plied to cause it to slough away. 

X. RUPTURES (HERNIA). 

The new-born infant is liable to several forms of hernia, and in 
some individuals there appears to be a remarkable predisposition to 
the disease. We know a family of three children in each of whom 
there existed at birth an umbilical hernia — in one, combined with a 
single, and in the third, with a double scrotal rupture. 

The form of protrusion which we most commonly meet with is the 
omphalocele, or umbilical hernia. In the early foetus we are to re- 
collect that there is naturally a pouch at the commencement of the 
umbilical cord, which contains convolutions of intestine, and that 
these are not retracted within the abdomen until some months of 
foetal life have elapsed. In the perfect state the opening at the navel 



144 



ACCIDENTS AND DISEASES AT BIRTH. 



should gradually close, until at birth it should only be capable of 
admitting the passage of the vein and arteries ; but in many instances 
such perfect closure does not take place — a round, well-defined 
opening, is left in the linea alba, and through this a sac of peri- 
toneum, containing a hernia, may protrude. The protrusion may 
vary very much in size and contents, but commonly it ranges from 
the bulk of a hazel-nut to that of a walnut, and contains intestine or 
omentum. The diagnosis is simple ; we find a tumour at the navel, 
which increases when the infant cries or coughs, and can be replaced 
when we relax the abdominal muscles, and use gentle pressure ; an 
empty pouch remaining ; and an aperture, into which we can insert 
the point of the finger, being perceptible in the wall of the abdomen. 
Instances are upon record, in which the liver and other viscera formed 
the contents of an omphalocele, but most commonly there is merely 
a fold of intestine. 

When the aperture in the linea alba is not very large, the pro- 
gnosis is usually favourable ; but much care and attention are 
required, both from the medical attendant and nurse. Until the funis 
has fallen off, and the navel healed, nothing more should be done 
than to apply a fold or two of old linen over the part in the ordi- 
nary manner of dressing the child ; but as soon as cicatrization is 
perfected, a more effectual course of treatment must be commenced, 
and the earlier this can be done, the better will be the chances of 
success. Our object is to keep the protrusion permanently within 
the abdomen, so as to permit a free scope to the natural efforts at 
closure of the opening. The means of effecting this are various. 
Spring trusses have been invented for the purpose, but are inappli- 
cable, from their strength, to the tender bodies of very young chil- 
dren. Sir A. Cooper recommends a section of an ivory ball to be 
applied over the umbilicus, and retained there by adhesive plaster 
and a belt. The plan which we ourselves usually adopt, and find 
successful, is to apply a graduated compress, made of white leather, 
spread with adhesive plaster, over the opening, and above this the 
common flannel roller or belly band. The apex of the compress, 
which is to be placed next the navel, should be as nearly as possible 
of the size of the opening ; the compress should consist of three or 
four pieces, — the largest being about three inches in diameter, — 
and a double stitch should be passed through them, and knotted 
externally, so as to keep each piece in situ. We should always 
apply the compress with our own hands, as great care is necessary 
to ensure a complete return of the hernia. Unless the child exhibits 
marks of uneasiness, it should not be removed until the plaster loses 
its adhesive quality, and then a new one should immediately be 
applied. In conducting the case, patience will be greatly exercised, 
as many months will be required for the completion of a cure, and 
this should be explained to the friends at the beginning. We have 
tried a plan, originally adopted, we believe, by Mr. VVoodroofe, of 
Cork, and which answers well when there is a small opening with a 
considerably elongated sac, but cannot be employed in broad, flat 
hernise ; it is, after reducing the contents, to hold the pouch firmly 



RUPTURES. 145 

between the fingers, and then wind round it a narrow strip of adhe- 
sive plaster, commencing as close as possible to the abdomen, and 
continuing to the apex. This plan may succeed, by causing adhe- 
sion of the walls of the sac, which will thus form a natural truss, 
and prevent protrusion through the opening in the iinea alba. A 
rougher variety of this plan was sometimes practised by Baron 
Dupuytren, by tying a ligature firmly round the pouch, as close 
as possible to the navel. We would not, however, recommend 
its adoption as the cicatrix formed after the falling off of the strangu- 
lated portion of the pouch could scarcely be firm enough to resist 
future protrusion, and the operation would have no direct tendency 
to diminish the opening in the abdominal wall. 

Inguinal hernia may also exist, at one or both sides, at the period 
of birth, and then constitutes what has been denominated hernia 
congenita. The distinctive character of this form of rupture is, 
that the protrusion descends into the sac of the tunica vaginalis, 
before the latter is closed, and thus comes to be in direct contact with 
the testicle. In many cases of congenital inguinal hernia, the testi- 
cle will not have descended from the abdomen ; and into this circum- 
stance we must particularly examine, by feeling for the testicle in 
the scrotum, as no truss should in any case be applied, as long as it 
remains within the belly. 

The diagnosis of inguinal rupture is less easy than that of ompha- 
locele, as it may be confounded with hydrocele, which is not uncom- 
mon in infants: or the testicle, while in the act of descending through 
the inguinal channel, may be mistaken for a hernia : after breech 
presentations, also, considerable tumefaction of the scrotum may 
exist, which should not be confounded with rupture. Hydrocele is 
to be distinguished from hernia by its transparency, and by our not 
being able to feel the cylinder of the intestine rolling under our 
fingers within the integument. The fluid may, however, be return- 
able into the abdomen as hernia is, and in like manner may be in- 
creased when the infant cries or coughs, so that caution is required 
in making our discrimination — the more so, as congenital hydrocele 
requires little or no treatment, usually disappearing spontaneously. 
The testicle is to be known by its solidity, and by not being usually 
returnable into the abdomen. The enlargement of the scrotum from 
pressure will be recognised from the history of the case, and will 
also, in general, rapidly subside. 

The principle of treatment in inguinal hernia is, of course, to keep 
the protrusion within the belly, and favour the closure of the ring. 
The accomplishment of this, however, is attended with immense dif- 
ficulty in the young child : the smallness of the pelvis renders it next 
to impossible to get any truss to fit ; and in early infancy, the con- 
stant wetting of the straps will cause chafing of the skin, notwith- 
standing the most careful attention. On these accounts we have, 
after repeated and patient trials, almost given up the idea of using 
a truss before the child is a year old ; and even at that age, we have 
been repeatedly foiled. A child subject to hernia should be kept in 
as tranquil a state as possible, and every means adopted to prevent 
13 



14 6 ACCIDENTS AND DISEASES AT BIRTH. 

it from crying, or using any exertion likely to increase the protru- 
sion. When this has been carefully attended to, and the parts bathed 
daily with cold water, we have often observed a spontaneous cure 
to be effected, without the employment of any artificial support what- 
soever. 

All the forms of hernia in the child may be the subject of strangu- 
lation, and require the operation, the performance of which is 
strictly within the province of the surgeon, and requires no remarks 
from us. 

XI. INJURIES RECEIVED DURING BIRTH. 

When, in the course of tedious labour, an extraordinary degree 
of pressure is exerted upon any part of the child, all the consequences 
of a contusion may result. Bloody tumours may be formed upon 
the head, or face, or in the scrotum ; or inflammations may be ex- 
cited, which will terminate in abscess, or even gangrene.* To all 
these injuries, the ordinary rules of surgery apply : the bloody tumour 
should be left to itself, and never on any account opened, as un- 
healthy suppuration would be thereby induced ; inflammation must 
be treated by the moderate use of cold lotions, as spirits or vinegar 
and water, and by preventing any continuance of irritation from pres- 
sure of clothes, &c. ; when suppuration or sloughing ensues, we must 
employ poultices. 

Considerable alteration is sometimes effected in the shape of the 
child's head ; and in face presentations, the features are often fright- 
fully disfigured ; but neither of these cases require or warrant any 
interference; and it will be often a matter of surprise to ourselves, 
how very rapidly the parts will return to their natural state. 

Fractures of the bones of the extremities^ are sometimes produced 
during birth, especially in cases of preternatural presentation, when 
turning or other manual interference is required. They unite readily, 
and are to be treated upon common principles, only adapting our 
means to the delicate organization of the child — making our splints, 
for example, of Bristol board, instead of wood, and carefully preserv- 
ing the skin from irritation. One thing we would recommend to the 
young practitioner in midwifery — viz., when such accidents un- 
fortunately occur, never to think of concealing them, but at once to 
inform the friends, and explain the steps necessary for the occasion. 
This is the honestest plan, and we sincerely hope it will also be 
found to be the best. 

When pressure by means of a blunt hook or fillet, or in any other 
way, has been applied to the groin or axilla, such injury may be 

* The foetus while yet in the womb is subject to many diseases, and among 
others to inflammation and its consequences. We lately had an opportunity of ob- 
serving a remarkable instance of this in the child of a prisoner in one of the jails 
of this city, which was born with two large sloughing ulcers upon the forearm. TNote 
to 2d Edition.] " 

t It is asserted by Schmidt, Jorg, Klein, and others, that in severe labours, with 
disproportioned pelvis, fractures of the cranial bones may be produced by the force 
of the pains alone. 



BLUE DISEASES — NINE-DAY FITS. I47 

done to the nerves in those situations, as will be followed by paralysis 
of the limbs. Such an affection is probably altogether beyond the 
reach of remedial art, and it is unnecessary for us to consider it at 
any greater length. 

XII. BLUE DISEASE (CYANOSIS). 

This term is applied to a morbid appearance of the skin, in which 
it assumes a blue, purple, or leaden colour, and which is occasionally 
observed in new-born iufants. The change of colour is particularly 
remarkable in the lips, cheeks, and nails, and is generally accom- 
panied with reduction of temperature, and paroxysms of difficult 
respiration, during which the blueness becomes deeper, and isextended 
over the surface of the body — the pulse stops, the extremities become 
cold, and syncope resembling death often occurs. From these fits 
the child may recover, but usually to be again attacked, and ulti- 
mately to perish in one of them. Anything which hurries the cir- 
culation — as crying, or quick motion, — is likely to bring on a 
paroxysm. 

The cause of these symptoms was attributed by Senac, Morgagni, 
and others, solely to a continuance of the foetal condition of the heart 
— or iu other words, to a permanent patency of the foramen ovale. 
Corvisart, however, observed the symptom of cyanosis in cases in 
which there was no communication between the ventricles ; and Dr. 
J. Crampton has met with others, in which there was no blue colour, 
and yet the openings between both auricles and ventricles must have 
been unclosed for many years.* Other causes, therefore, must exist ; 
and in new-born children, we conceive, it may often be accounted 
for by the imperfect filling of the lungs which we have already 
spoken of as having been noticed by Dr. Ed. Jorg. When the disease 
arises from organic imperfection, the prognosis is highly unfavour- 
able, and nothing can be done by art ; yet the unfortunate subjects 
sometimes drag on a wretched existence for years, as in Morgagni's 
well-known case of the girl who survived to her sixteenth year 
with a foramen ovale so large as to admit of the passage of the little 
finger through it. When the symptom belongs to an imperfect filling 
of the lungs with air, we must have recourse to those means of 
exciting respiration indicated under the head of ' still-born children,' 
and may sometimes be successful in our efforts. During a paroxysm, 
all we can do is to sprinkle the child's face with cold water, and 
expose it freely to cold air. 

XIII. NINE-DAY FITS (TRISMUS NASCENTIUM). 

This fatal affection is stated to commit great ravages among infants 
of all classes in warm climates,! but in this country, although occa- 

* See Med. Trans. Coll. of Physicians in Dublin, vol. i., new series. 
f It is also very fatal in the Westmann Islands, on the southern coast of Iceland. 
See M'KenzWs Iceland, 



14 8 ACCIDENTS AND DISEASES AT BIRTH. 

sionally to be met with in private practice, it may justly be considered 
as an hospital disease. Its ordinary period of occurrence is within 
nine days from birth, — about the time of the falling off of the funis, — 
and it appears in two forms, distinguished by nurses as " black" and 
" white fits." The first of these is violent and rapid in its progress, 
terminating fatally in from eight to thirty hours ; the second may be 
protracted to three, five, or even nine days. 

Sometimes the disease sets in without any warning; in other cases 
there are certain premonitory symptoms, as whining and starting 
during sleep, twisting of the upper extremities, the appearance of a 
livid circle about the lips, sudden changes in the countenance, and 
compression and puckering of the mouth, accompanied with a pecu- 
liar screeching. The child's appearing to smile during sleep is also 
commonly considered as an indication of the approach of fits. An 
extraordinary greediness for food or suck, as if occasioned by inward 
pain, is sometimes observed. The stools may be regular and natural, 
or they may exhibit considerable derangement, being greenish, slimy, 
and knotted. When the paroxysm actually comes on, the infant is 
seized with violent, irregular spasms of the muscles, particularly of 
those of the limbs and face, recurring at uncertain intervals. In the 
" black fits," the muscular contractions are very violent ; there is 
foaming at the mouth ; the thumbs are turned firmly into the palm 
of the hand; the jaws are closed, and any attempt to separate them 
considerably aggravates the paroxysm; the face, and often other 
parts of the body, are swoln, and of a dark copper colour ; during 
the interval, the muscles retain a greater or lesser degree of rigidity. 
In the " white fits," there is not so much violence ; the face is pale, 
and the body becomes quickly emaciated. Both are equally fatal. 

With respect to the pathology of trismus, nothing is certainly 
known ; but the researches of Dr. Joseph Clarke* make it highly 
probable, that a powerfully predisposing cause exists in a vitiated 
state of the atmosphere of large hospitals ; and Professor Collest has 
ingeniously put forward the suggestion, that this operates by inducing 
"an unhealthy or unkindly form of inflammation or ulceration" at 
the navel, and that the disease is in fact a species of traumatic tetanus, 
having its immediate cause in the wound occasioned by the separa- 
tion of the cord. This view has, however, been impugned by Dr. 
Labatt, who has published particulars of some post-mortem exami- 
nations in which no appearance, satisfactorily accounting for the dis- 
ease, showed itself in the cord.± 

The views of Dr. Clarke led him to pay much attention to the 
prevention of trismus in the Dublin Lying-in-Hospital, by establishing 
a free ventilation, and perfect cleanliness in the wards; and his 
numerical statements, certainly, appear strongly to corroborate his 
opinions. They are also further borne out by the facts contained in 

* Tran. R. I. Acad. vol. iii. 

| Dub. Hosp. Reports, vol, i. 

% Ed. Med. and Surg. Journal, yoI. xv. 



INFANTILE ERYSIPELAS. 149 

Dr. Collins' book,* to which we may refer the student and statistician 
for much valuable numerical information, upon this and other sub- 
jects connected with midwifery. Whether we can fully assent to 
the exact number of lives (16,371) said to have been saved by Dr. 
Clarke's suggestions, is a matter of very trifling importance ; but we 
would strongly recommend that his principles with respect to venti- 
lation and cleanliness, shouM be carried into effect, as perfectly as 
possible, in every lying-in institution. Professor Colles suggests as 
a preventive measure, in every case, the propriety of dressing the 
umbilicus with spirits of turpentine, from the birth of the infant ; but 
the small average occurrence of the disease, especially in private 
practice, scarcely appears to demand such a step. 

With respect to the treatment of trismus nascentium ; when it has 
once set in, we believe that every thing is empiricism, and that little 
is to be expected from any plan. We have tried, or seen tried, 
almost every variety of treatment — mercury, leeching, blistering, 
opium, tobacco, &c, &c, — without any impression being made upon 
the affection ; and we must candidly confess, it is not in our power 
to propose any means with confidence. Dr. Breen,t of this city, 
speaks encouragingly of the administration of an eighth of a drop of 
laudanum every second hour until narcotic effects are produced, 
together with " a grain and a half of calomel every fifth or sixth hour 
up to the third time ; afterwards not more unfrequently than twice or 
three times in twenty-four hours, with intermediate doses of castor 
oil, in the quantity of a large-sized tea-spoonful, sometimes joined 
with a third part of spirits of turpentine." Dr. B. has not found the 
warm bath productive of advantage. 



XIV. INFANTILE ERYSIPELAS. 

Inflammation of an erysipelatous nature sometimes attacks infants, 
especially those born in lying-in hospitals. The disease in its worst 
form appears about the navel, or lower part of the belly (from which 
latter situation, it has sometimes been denominated erysipelas pubis) ; 
but it also frequently attacks the limbs, and particularly in the vici- 
nity of joints, as the ankle and wrist. 

It is a very dangerous affection, running quickly into suppuration 
or gangrene, and usually occurs at periods when the existence of 
other malignant diseases, as diffused infl animation, puerperal fever, 
scarlatina, &c, prove the constitutio anni to be of a typhoid charac- 
ter. Its affinity with such affections is also further shown by the 
morbid appearances observable in fatal cases of the disease — the 
different cavities being usually found to contain effusions of curdy 
gelatinous lymph and serum, and the organs often exhibiting soften- 
ing, and infiltrations of sero-purulent matter. 

Infantile erysipelas first appears in the form of a dark red, shining 

* Pract. Treatise on Midwifery, by Robt. Collins, M.D. London, 1835. (Pub- 
lished in the Select Medical Library.} 
t See Dub. Med. Journal, vol. viii. 
13* 



15 ACCIDENTS AND DISEASES AT BIRTH. 

spot, which quickly extends in size, and becomes of a purplish colour ; 
there is not a great deal of swelling, but the skin is tense and very- 
hard. When it commences on the belly, vesications, destruction of 
the cellular tissue, and gangrene of the skin, quickly follow. The 
genital parts are not unfrequently destroyed altogether ; and we have 
sometimes seen the scrotum become black and slough away, leaving 
the testicles bare and hanging loosely by the cords. In such cases, 
the fever is of a typhoid kind and very severe, usually carrying off 
the child in a very few days. The erysipelas which attacks the 
limbs, in the first instance, is milder in its nature ; although suppura- 
tion often follows, prognosis is not so unfavourable as in that which 
commences upon the abdomen, as it less frequently runs into gan- 
grene. Before the setting in of erysipelas, the bowels are generally 
deranged, the stools being offensive, slimy, and knotted. It often, 
however, makes its attack so speedily after birth, that we have not time 
to recognise any premonitory signs. The general symptoms during 
the existence of the disease are great restlessness and peevishness, 
diarrhoea, with ill-conditioned motions, very rapid, feeble pulse, and, 
towards the termination, a state of coma. 

The prognosis is very unfavourable, and yet (so little are we war- 
ranted in despairing of children under the most doubtful circum- 
stances) we have seen a case recover in which the whole scrotum 
and skin about the pubes had sloughed away, the bare testicles being 
again covered up by an extension and cicatrization of the neighbour- 
ing integuments. 

In treating infantile erysipelas, we must hold in view the circum- 
stances under which it occurs, and its usual course. It is commonly 
a disease of hospitals, and must therefore be presumed to have its 
predisposing cause in some impurity of the atmosphere ; accordingly 
we should lose no time in transferring the child, if it be practicable, 
to a different and well-ventilated apartment : this we conceive to be 
an essential step in the treatment. From the usual course of the 
disease, its quickly running into gangrene, and the fever being 
typhoid, we learn the necessity of supporting the child's strength, at 
the same time that the gastric derangement demands from us a care- 
ful attention to its bowels. Should the mother not have sufficient 
milk, or not be free from disease, we must at once procure a wet 
nurse ; and if the child be unable, or disinclined to suck, a tea-spoon- 
ful of white wine-whey must be administered every hour or half 
hour. An alterative aperient should at once be given ; and when it 
has operated, small doses of quinine (one-third to one-fourth of a 
grain), every three or four hours, in conjunction with one-fourth of 
a grain of aromatic powder. Ammonia has been recommended by 
some ; but we think the wine- whey a better stimulant, as combining 
also nutritive matter. With respect to local treatment ; in the first 
instance, we probably cannot do better than to dust the part with 
starch-powder or common flour ; and subsequently, when suppura- 
tion or gangrene is approaching, most relief will be given by warm 
fomentations and light poultices, as of bran or chamomile flowers ; 
or the fermenting poultice. When matter is formed, incisions will 



ABSCESSES — INDURATION OF THE CELLULAR TISSUE. 151 

be required in order to give exit to the sloughing cellular membrane, 
and prevent, as far as possible, further destruction. Underwood and 
Burns recommend, as local treatment, compresses of linen wrung out 
of camphorated spirit ; but we rather think we have seen more 
benefit result from the use of warm applications. Perhaps, when 
the disease attacks the limbs, it would be advisable to try a modifica- 
tion of Mr. Higginbottom's plan in erysipelas, by drawing, with a 
pencil of lunar caustic, a sort of cordon round the diseased part. 
We cannot speak from experience of this suggestion ; but it appears 
worth trying, especially as erysipelas, when it attacks the limbs, is 
frequently of an erratic nature. 



XV. ABSCESSES. 

We have frequently had occasion to treat large collections of matter 
in very young children, which, if the short course of life already per- 
mitted to the little patient did not forbid, we should be almost tempted 
to call chronic abscesses. These formations of matter we do not 
recollect to have seen noticed by any author ; yet they are of very 
frequent occurrence. Their usual situation is in the axilla, neck, or 
lower part of the leg; but we have observed them in almost every 
part of the body. They set in and increase with little appearance of 
inflammation, and often attain a very considerable size, without 
having excited any general fever. We have sometimes given exit 
to a wine-glassful of matter from one existing in a child of a few 
weeks old. The disease consists at first of a tumour, apparently not 
very painful to the touch, until it approaches the surface, when the 
skin becomes inflamed, and a process of pointing commences. We 
can then satisfy ourselves, by the touch, of the presence of a fluid — 
and the sooner we give vent to it, by a small opening with a lancet, 
the better. The pus is sometimes fetid ; at others healthy. After 
being opened, the abscess commonly gets well without any treat- 
ment, beyond the use of a poultice, being required. 

XVI. INDURATION ON THE CELLULAR TISSUE (OEDEME DU TISSU 

CELLULAIRE DES NOUVEAUX-NES ', SKIN-BOUND DISEASE). 

This appears to be a very common disease in the French hospitals, 
and extremely fatal ; so much so, that in the years between 1808 
and 1811 there died, in the Hospice des Enfans trouvh, 576 out of 643 
who were attacked. In Great Britain, however, it is not by any 
means so common. It occurs during the first few days after birth, 
and in some instances the infants has been born with it. It usually 
attacks premature or feeble children, in whom respiration has not been 
fully established, andcommences in the extremities — most commonly 
in the feet. These parts become somewhat swollen, dry, hard, and 
cold. The skin is sometimes of the natural colour ; at others, livid 
or purple. It appears as if stretched tightly over the subjacent parts, 
and is cold and hard, pitting slightly upon pressure. From the ex- 
tremities the disease commonly proceeds, with rapidity, to the trunk 



152 



ACCIDENTS AND DISEASES AT BIRTH. 



of the body, the whole or parts of which it affects in like manner. 
The diminution in temperature is remarkable, and the body often 
appears to be acted upon by external heat merely as so much dead 
matter. 

No febrile condition accompanies this affection, wherein it differs 
from infantile erysipelas, which in other respects it much resembles. 
The child will not suck, is restless, and continually whines in a manner 
compared by Dorfmiiller to the crying of young mice. Respiration 
becomes gradually more and more difficult, until death ensues, usually 
before the fourth day, but sometimes so late as the second or third 
week. The prognosis is very unfavourable ; but in mild cases, the 
respiration sometimes improves, heat begins to be evolved, and 
recovery slowly takes place. 

Post-mortem examinations show the results of this disease to con- 
sist of an effusion of yellowish or greenish sero-albuminous fluid into 
the cells of the cellular membrane, both the subcutaneous tissue, and 
that which lies between the muscles. The peculiar hardness has 
been attributed by some to the coagulable quality of the effused fluid, 
which was analysed by Chevreul ; but we have the authority of Dr. 
Carswell* for stating that this quality does not exist in a greater 
degree in the serum in question that in that which constitutes the 
oedema of adults; and that further, it is not found in a coagulated 
state in the cellular tissue of children subject to this disease. It is 
probable that the peculiar hardness and tightness of the skin depends 
upon the condensation of the fat produced by the mechanical pressure 
of the effused fluid. All observers are agreed upon the constant 
existence of congestion in the large veins, and accumulation of black 
blood in all the viscera, as concomitants of this disease ; which state, 
however it may be produced, sufficiently explains the diminution of 
temperature, serous effusion, and other phenomena. Other lesions, 
which are only occasionally observed, as open foramen ovale, inflamed 
conditions of organs, &c, must be merely considered as accidental 
coincidences. 

With respect to the remote cause, much difference of opinion exists. 
By Dr. Andry, who first accurately^ described the disease, and sub- 
sequently by M. Duges, it was attributed to cold ; M. Breschet con- 
ceived it to depend upon an open state of the foramen ovale ; M. 
Denis considered it to be an inflammatory affection of the cellular 
membrane ; M. Billard assigns several predisposing causes, the most 
prominent being a natural debility of the child, which of course is 
merely an asylum ignorantise. It appears to us highly probable, 
that a frequent cause may be the imperfect filling of the lungs with 
air, at the time of birth, of which we have already spoken. 

Treatment in so fatal a disease is, of course, the subject of much 
difference of opinion. The earlier plans had for their object the 
application of heat by means of the warm and vapour bath, and 
wrapping the child in wool or cotton. The lowness of temperature, 

* Cyc. of Pract. Med. article Induration. 

t It was previously noticed by Drs. Denman and Underwood. 



JAUNDICE — PURULENT OPHTHALMIA OF INFANTS. 153 

however, is merely a symptom of the state of commencing asphyxia ; 
and we have already observed that that state is not likely to be 
removed by the application of external heat alone. We must 
endeavour to lessen the venous congestion, and if we succeed in 
doing so, the production of heat will proceed naturally. For this 
purpose we would recommend friction with warm flannel ; the 
administration of an emetic of ipecacuan, for the purpose of remov- 
ing mucus, and exciting respiration ; and the internal use of stimu- 
lants, as warm wine-whey. We cannot put forward this plan as the 
result of experience ; but we conceive it to be based upon a rational 
view of the pathology of the disease. Palletta recommends leeches 
to be applied to the oedematous parts, as a means of promoting cir- 
culation ; but his plan has not succeeded in other hands. 

XVII. JAUNDICE (ICTERUS NEONATORUM, OR YELLOW GUM). 

A more or less marked yellowness of the skin and tunica conjunc- 
tiva of the eye is a very common occurrence with infants of two or 
three days old. This, in ordinary cases, appears to depend merely 
upon the active commencement of the secretion of bile ; more than 
is required for the uses of the digestive function being formed, and 
then disposed of by means of the skin and other excreting organs. 
Viewed in this light, it can scarcely be called a disease, commonly 
disappearing spontaneously, and requiring no medical treatment. 
When it does not go off in two or three days, we may set matters to 
rights by the administration of a drachm of castor oil, or two or three 
grains of rhubarb with one of hydrargyrum cum creta. 

Jaundice may occur in a young child as the result of malformation 
or obstruction of the biliary ducts ; but under such circumstances it 
is permanent, and if there be an organic defect, cannot be removed, 
and will probably prove fatal. 



XVIII. PURULENT OPHTHALMIA OF INFANTS. 

An inflammation not unfrequently attacks the eyes of new-born 
children, which is speedily followed by a copious secretion of pus 
from the conjunctiva, and when neglected, often terminates in 
sloughing of the cornea, or permanent opacity of that tissue. This 
disease commonly sets in the second or third day after birth, and 
commences with increased vascularity of the conjunctiva lining the 
eyelids, which latter become swollen and permanently closed. The 
inflammation soon extends to the conjunctiva of the eyeball — the 
swelling of the lids increases very much, and a copious discharge of 
thick, white, purulent matter ensues. If we attempt to open the 
eye at this period, a gush of matter takes place, and, frequently, the 
lower lid is everted, exhibiting its internal surface highly inflamed 
and of a bright red colour. In some severe instances, the tumefac- 
tion of the lids is so great as to cause eversion without its being the 
result of an attempt at opening the eye. We can seldom get a view 
of the cornea, as the intolerance of light is so great as to cause a 



154 ACCIDENTS AND DISEASES AT BIRTH. 

turning upwards of the eyeball upon every attempt at separating 
the lids. 

Some difference of opinion prevails as to the cause of purulent 
ophthalmia. It is attributed by many solely to a specific infection 
communicated during the birth of the child ; while by others it is 
supposed to be a species of epidemic ; and others, again, attribute it 
to cold, or the stimulus of too much light. It is probable that any 
one of these causes may occasionally produce it ; but our own expe- 
rience certainly goes in support of its usually being the result of 
infection, as we have, in a large majority of instances, traced it to a 
gonorrheal or leucorrhceal discharge existing in the mother before 
parturition. The prognosis is usually favourable, if the case be seen 
in time, and carefully attended to ; but it has too often happened to 
us to be first called upon when sloughing or opacity had already 
taken place. 

The treatment of purulent ophthalmia has been conducted upon 
very different principles by different practitioners. The violence of 
the inflammation has induced some to apply a leech to the lid or 
temple, in almost every instance, and to repeat the application as 
often as three or four times. We have, however, but seldom found 
it necessary to draw blood at all ; and the most protracted examples 
of the disease, we have seen, have been those in which leeching was 
repeatedly employed. It has frequently appeared to us that the loss 
of blood by two or three leeches — (it is to be remembered that we 
are treating an infant two or three days old) — produces such general 
and local debility as favours very much a protracted continuance of 
the discharge, merely by causing relaxation of the inflamed vessels. 
It is only then, in an extreme case, when the inflammation is very 
rapid and violent, and the child strong, that we would venture upon 
the application of a leech. Our common plan is to employ astringent 
or stimulant collyria from the commencement ; and by the use of 
these, and the most scrupulous attention to cleanliness, we have 
generally been successful in saving the eyes. The kind of collyrium 
to be used is not of great consequence. A very good formula is six 
grains of alum to an ounce of rose water ; or three grains of sulphate 
of zinc to the same quantity of rose water. We generally prefer 
collyria of this description to those composed of nitrate of silver. 
Much benefit has, however, been derived, in chronic cases, from the 
use of a strong solution (say ten grains to the ounce) of the latter 
substance in distilled water. A drop or two of the collyrium should 
be introduced into the eye three or four times a day ; and the dis- 
charge should be frequently removed by dropping from a sponge, or 
injecting between the lids, lukewarm water, or chamomile tea. 
Without attention to cleanliness, and removal of the discharge in this 
way, any treatment we can adopt, whether energetic or mild, will 
be quite inadequate to the safe management of the disease. When 
the inflammation is severe, and the lids adhere strongly together, a 
poultice of bread and cold water enclosed in a muslin bag, and 
applied between the periods of washing, will be found of great 
service. The application of the solid nitrate of silver to the inflamed 






PURULENT OPHTHALMIA OF INFANTS. 



155 



eye has been tried by some, and no doubt often with benefit ; but 
we are never desirous in our practice of trying what can be done 
with impunity, but rather of safely removing a disease with the least 
possible artificial interference. In conjunction with the local treat- 
ment, we must attend to the condition of the child's bowels — and 
will generally perceive a necessity for aperients, and if the intestinal 
discharges be unnatural, for small doses of hydrargyrum cum creta 
as an alterative. Should the discharge begin to decrease, we must 
continue our attentions to cleanliness, and persevere in the use of the 
astringent collyria, as the disease is likely to relapse. Even when 
considerable opacities of the cornea remain, in severe or improperly 
treated cases, so active are the absorbents of the child, that we shall 
frequently find the speck gradually to disappear. Many cases of 
the purulent ophthalmia of infants depend upon the state of the con- 
stitution, and are consequently only removable by an improvement of 
the general health. We have known change of air or change of 
nurse, especially the former, to act like a charm in the cure of this 
disease. 

The following remarks on this important subject will be read with 
the interest which attaches to every contribution to ophthalmic 
surgery, from the able pen of Professor Jacob : — 

My dear Maunsell, 

You ask me to give my opinion as to the treatment of the purulent 
ophthalmia of infants, for insertion in the edition of your's and Dr. 
Evanson's book on Diseases of Children, now going through the 
press. This I can do without adding much to the bulk of your 
volume, or imposing much labour on myself. In fact the matter 
appears to me to be in a nut-shell. If we can prevent or stop the 
slough, abscess, or ulceration of the cornea, whichever it is, or what- 
ever we call it, we do almost all that is required, nature sooner or 
later does the rest. This, however, is the great difficulty, and I am 
skeptical as to our power to overcome it. As in other diseases medi- 
cal men, with great confidence and composure, attribute the success- 
ful issue to their treatment, when the recovery is a natural result, 
and, perhaps, even a result obtained by the operation of natural causes 
in defiance of the counteracting influence of art. I wish those who 
boast of their " cures " would have the goodness to let us know how 
many per cent, of this disease recover if not meddled with at all. If 
we knew why the cornea suffers this destruction in this complaint 
we might, perhaps, suggest a remedy with more confidence ; but of 
this we are entirely ignorant notwithstanding plausible theories and 
hardy assertions. We are told that this structure gangrenes or 
sloughs, because its vitality being lower than surrounding parts, it 
cannot resist the consequences of that inflammatory action which other 
textures bear with impunity, which is, after all, a mere begging of 
the question. What grounds have we for assuming that the vital 
functions are less energetically or effectually exercised in this piece 
of organization ? On the contrary, we have good grounds for believing 



156 



ACCIDENTS AND DISEASES AT BIRTH. 



that its powers of life and growth are of the most active kind. In 
general inflammation of the eyeball commonly called iritis, the cor- 
nea is more implicated than in this inflammation of the conjunctiva, 
yet we do not find it gangrene or slough. All we know, I believe, 
is that in this disease the cornea often suffers from gangrene, abscess, 
or ulceration, one, or both, or all three, and that the consequence is 
cicatrix or opacity, more or less destructive to vision. 

As you have argued in a preceding paragraph, neither the results 
of the treatment, nor the reasoning upon which it is founded, are 
conclusive as to the value of bloodletting in this disease. We are 
prejudiced in favour of this resource in all inflammations, because 
we see its value in many ; but I am sorry to say in inflammations of 
this mucous membrane, and, perhaps, of mucous membranes in 
general, we have no reason for being very sanguine as to its decisive 
beneficial influence. If an infant be vigorous and full of blood I 
would apply a leech or two, and allow the bites to bleed until vas- 
cular action is enfeebled, but more with the view of reducing the 
inflammation of the lids, and thereby diminishing the tumefaction 
and consequent pain, than the hope of preventing the formation of 
the slough, abscess, or ulceration. On the contrary, if we are to look 
on the mischief, as gangrene or slough in the first stage, we have 
good reason for fearing that the debility produced by depletion may 
contribute to that consequence. It has been proposed, and many, I 
believe, practise it, to drop a strong solution of nitrate of silver into 
the eye even in the first or active stage of inflammation, with the 
view of preventing the sloughing of the cornea. How such an effect 
can be expected to follow such a cause, I cannot understand, but the 
advocates of the remedy will tell me they do not pretend to explain 
why it is so, but to state that it is so. Now this is not quite so cer- 
tain as they suppose. That many babes escape blindness who are 
thus treated I admit, but whether they escape in spite of it, or in con- 
sequence of it, is another affair. If I had a child of my own suffer- 
ing from purulent ophthalmia, 1 am sure I would not put strong 
solution of nitrate of silver into its eyes in the first or inflammatory 
stage. 

I find it inculcated that the purulent discharge should be constantly 
carefully removed, and directions are given for syringing and wiping 
the lids to free them from it. If this advice be given from a belief 
that the purulent matter is injurious to the inflamed surface, or unfit 
to form a covering for it, the notion is surely a mistaken one. The 
purulent matter is nature's dressing, and the art of man has never 
invented a better or as good a one. It may, perhaps, give trouble 
from its accumulation, should the lids be glued up by its drying on 
their edges, but that it scalds or irritates the eye cannot in my opinion 
be admitted. It may be well, whenever the baby awakes, just to 
draw the lids gently up and down, and delicately to squeeze out the 
matter which has gathered during sleep, and then to wipe it off the 
skin with a soft sponge, but to wash it all out with a syringe, or 
brush it off with a hair pencil, is what I would forbid. After the 
period of active inflammation has passed, and that the profuse puru- 



RED GUM. 157 

lent discharge constitutes the principal, if not the only cause of an- 
noyance, it must then be stopped, and this, I believe, may, in the 
great majority of cases, be effected by the solution of nitrate of silver, 
ten grains to the ounce of water, or if this be ineffectual, fifteen or 
twenty may be employed without danger. Before dropping the 
solution into the eye the purulent matter must, however, be removed. 
This I effect by gently pulling open the lids, and then squeezing 
them together, after which I drop some lukewarm water between 
them, out of a hair pencil, and squeeze them gently again, then I let 
the baby become quiet, and suddenly raising the lid drop in the solu- 
tion. Next to the nitrate of silver solution I prefer that of alum ; it 
has more astringent with less stimulating qualities than, perhaps, 
any other. Five grains to the ounce of water may be employed for 
common use, and the saturated solution once in the twenty-four 
hours. 

I believe strong solutions of nitrate of silver are sometimes resorted 
to, and other active remedies adopted, with the view of preventing 
the enlargement of the palpebral glands, commonly called granular 
conjunctiva. I have even heard of the solid nitrate of silver being 
rubbed to the inside of the lids for this purpose, which I hope is not 
the case. As far as my experience has gone, the mucous glands of 
the conjunctiva lining the eyelids, do nor become enlarged from in- 
flammation at this time of life, and therefore the so-called granular 
conjunctiva is not to be feared from this disease. In fact, as I have 
said before, if the cornea escapes from the destruction which some 
call slough, and some call abscess, but which may, perhaps, be either 
or both, and the consequent ulceration, nature sooner or later effects 
the cure. I do not here enter on the treatment of the slough, abscess, 
or ulcer of the cornea, the prolapsed iris, the opacities or the staphy- 
loma which take place in this disease, because I am sure that the 
safest course to be pursued by the accoucheur when any of these 
occur is to hand over the case to the management of a good surgeon, 
who understands the treatment of it. He will gain little credit should 
the case recover perfectly, and must bear all the blame should it be 
otherwise. 

Believe me, 

Yours, very truly, 

A. JACOB. 
Dublin, Oct. 1, 1841. 



XIX. RED GUM (STROPHULUS INTERTINCTUS). 

Almost every infant is affected three or four days after birth, with 
an eruption of papula?, which has received the foregoing appellations. 
In its ordinary form this consists of a few red pimples, appearing in 
greatest number upon the face, neck, and hands, and interspersed 
with diffused red patches. When there is a slight degree of redness 
a distinction has been made, and the eruption termed strophulus 
14 



158 DENTITION. 

albidus ; and a rash of the same nature which occurs during denti- 
tion in larger quantity and with more irritation has been termed 
strophulus confer tus. The ordinary red gum of infancy can scarcely 
be called a disease. It arises probably from the slight irritation at- 
tendant upon the new circumstances under which the skin and 
mucous membranes are placed, and requires no treatment. The 
nurse constantly looks for its appearance as a favourable occurrence ; 
and we believe it merely indicates a healthy state of sensibility of 
the integuments and mucous membrane. 



XX. SWELLING OF THE BREASTS. 

The breasts of infants, both male and female, contain at birth a 
secretion somewhat resembling milk, and which is generally sup- 
posed by the attendants to require speedy removal. Accordingly, they 
frequently set about pressing the part until inflammation, and occa- 
sionally an abscess is produced. This notion, however, is altogether 
erroneous. No measure for getting rid of the secretion is necessary ; 
and we should forbid any attempt at adopting one. We have re- 
peatedly had to open an abscess produced by pressure, in the way 
alluded to, but which, nevertheless, was always attributed by the 
nurse to the want of sufficient removal of the fluid in question. 



CHAPTER VII. 

DENTITION. 

Absence of teeth has already been remarked as a character be- 
longing to the mouth at birth. Infants, however, have been born 
with teeth ;* while in a few instances none have ever grown. The first 
appearance of teeth usually begins about the sixth or seventh month. 
It may be much earlier, as the third or fourth month ; but oftener is 
delayed to a later period ; the age at which the teeth first begin to 
appear varying much, and often without any apparent relation to 
the constitutional powers of the child. The process is commonly 
completed during the first year, or year and a half; but may be pro- 
tracted beyond the second year. 

* When teeth are in the gums at birth (usually the central incisors of the under 
jaw), they occasionally cause distress by irritating the tongue during the act of 
sucking. In such cases, their edges, when sharp, may be filed down ; or the teeth 
themselves extracted. But unless inconvenience arise, it is well to leave them 
undisturbed ; for they are not always, as stated by Mr. Fox, merely the upper parts 
or crowns of teeth, without fangs. 



DENTITION. 159 

The number of the first set, or milk teeth, is 20 ;* and they make 
their appearance usually in pairs, — those of the lower jaw coming 
out before the corresponding pairs of the upper; and a degree of 
uniformity is to be observed in the order and times of their appear- 
ing. The middle incisors are those that first come out; then come 
the lateral incisors, and after these the anterior molars ; but not uni- 
formly (as some assert), for the canine teeth occasionally precede. 
The posterior molars are the last to appear, at a period varying from 
the 20th to the 30th month. 

Mr. Bell (in his Treatise upon the Teeth) expresses these facts, 
as to the appearance of the teeth, in the following tabular form: — 

From 5 to 8 months the four central incisores. 
From 7 to 10 do. the four lateral incisores. 
From 12 to 16 do. the four anterior molares. 
From 1-1 to 20 do. the four cuspidati. 
From 18 to 36 do. the four posterior molares. 

In the foetus the rudiments of the teeth are observable about the 
second or third month ; and are found (as they advance in size) to 
consist of a double membranous sac. From the bottom of this arises 
a pulp, which is composed of nervous and vascular matter, and 
around which is found a colourless consistent fluid, which is gradu- 
ally absorbed as the pulp increases in size. On the summit of this 
pulp (upon which the future tooth is moulded) ossification becomes 
visible about the end of the third month. The enamel is not formed 
until afterwards, which it most probably is by secretion from the 
vascular membrane lining the sac.t The groove or channel which 
had run uninterruptedly along the edge of the jaw-bone, now becomes 
divided by osseous septa, which grow across ; and thus the alveoli 
are formed. 

At birth ossification is already advanced in most of the first set of 
teeth ; much of the crowns of the molars are formed, and those of 
the incisors are in general completed. Subsequent to the ossification 
of the crowns of the teeth, that of their roots takes place ; and as ossi- 
fication advances, the roots of the teeth continue to elongate, until 
first those of the incisors, and subsequently others, can no longer be 
contained within the alveoli, and the tooth is thus pushed upwards, 



* 4 Incisors in each jaw, 8 

2 Canines, 4 

4 Molars, 8 

—20 
In the second set there are — 

4 Grinders additional in each jaw, 8 

2 Dentes Sapientiae do. 4 

—32 
Just previous to the temporary shedding of any of the teeth there are no less 
than 48 teeth, at one time, in the two jaws: namely — 

Deciduous teeth (all perfected), 20 

Permanent do. (more or less perfect), 28 

—48 
f According to recent researches, (by Mr. Nasmyth and others,) the tooth is 
formed by conversion of the vesicles or cells of the pulp, into the cells or fibres of 
the ivory, by the deposition of osseous matter. 



160 DENTITION. 

the development of the alveoli themselves aiding in the process. The 
consequent absorption of the surface of the gum, and the apex of 
the enveloping sac, at length makes its way for the appearance of 
the tooth, which is then said to be cut. 

This process is a natural one, and does not necessarily lead to dis- 
eased action ; but such is liable to occur in consequence of the irrita- 
bility of the infant constitution, which is at this time particularly re- 
markable, as well as the proneness to sympathetic disturbance. 
Some irritation must attend the passage of the tooth through the 
gum ; and this is caused both by the pressure of the crown of the 
tooth on the parts above, and of the root on the dental nerves below. 
Hence arises pain; and to this we are to attribute, as a chief cause, 
the morbid sympathies that accompany dentition. The degree to 
which these may amount, however, depends more upon the state of 
the infant at the time, than the extent of local irritation caused by 
the tooth ; for we see what little suffering attends upon cutting the 
large double-teeth compared with the small ones, which preceded 
them at a time when the susceptibility of the infant constitution was 
at its height. 

Certain symptoms must naturally accompany dentition, however 
favourably it may proceed ; and the attendant determination of blood 
to the parts contributes to these. Saliva flows in increased quantity 
from the mouth when a child is teething, and the gums are more or 
less swollen, hard, and hot. Thirst appears to be felt ; for the child 
takes the breast more frequently, though for shorter periods than 
usual, dropping it, as if from the tender state of the gums — but the 
fingers, or whatever it can grasp, are often thrust into the mouth. 
The child is frequently fretful or peevish, and gets sudden fits of 
crying, or starts in its sleep, which is liable to be disturbed. The 
cheeks are occasionally flushed ; and increased heat, or pulsation, 
may be felt about the head. A tendency often exists to disturbance 
of the stomach or bowels, the food being rejected ; or slight diarrhoea 
attends. These symptoms, however, are not to be looked upon as 
constituting disease, but in general work their own cure, the local 
excitement being relieved by the inordinate flow of saliva, and the 
constitutional disturbance by the attendant diarrhoea ; while some of 
them are obviously but indications of an increased activity in the 
process of ossification, as they often precede the appearance of the 
tooth by many weeks but subside again in some days, from eight or 
ten to fourteen. This may be looked upon as the first stage of den- 
tition ; and is called, in popular phraseology, "breeding the teeth." 
The symptoms again occur, but in a somewhat modified form, when 
the tooth begins to approach the surface of the gum. 

The relation which subsists between dentition and disease, as 
arising directly therefrom, or merely complicated therewith, is most 
important; and upon a right understanding of this, will depend our 
success in the management of children while teething. On no sub- 
ject does more misapprehension, in common, prevail. All complaints 
occurring about this time are attributed to dentition as their cause, 
and hence are frequently mismanaged, being altogether neglected as 
salutary efforts of nature, or attention paid only to the state of the 



DEXTITIOX. 161 

gums ; yet the just medium seems sufficiently obvious. Whenever 
a child is ill about the time at which the teeth may appear, we should 
carefully examine the gums, to ascertain how far the symptoms may 
be connected with their' state ; and act accordingly. But attention 
is not to be confined exclusively to the gums, nor are we to rest 
satisfied with remedial means directed thereto. The illness may be 
merely an accidental complication, or, even if connected with teething, 
may require active treatment on its own account. In a word, neglect 
of the state of the gums may render our other treatment unavailing, 
or attention to this alone, prove inadequate. 

The morbid phenomena so often witnessed during dentition are 
influenced, first, by the degree of irritation caused directly by the 
teeth : secondly, by the degree of susceptibility of constitution existing 
at the time: — the age and condition of the child affecting both. 

The more suddenly the teeth are developed, and the greater the 
number coming out together, the more will be the local irritation, 
particularly should any obstacle be presented, as a disproportion 
between the rate of development of the teeth and the jaws, &c, &c. 
The earlier the age at which dentition commences, the severer is 
likely to be the constitutional disturbance, from the greater suscepti- 
bility of the system ; for the natural susceptibility is heightened by 
the rapid evolution which the brain is undergoing at this early period, 
in addition to which, there is local determination of the blood, caused 
by the process going on : so that the nervous system is in the highest 
state of irritability: hence is symptomatic disturbance of all parts, 
but more particularly of the brain, so liable to be induced at the time 
of teething. The proneness to this will be increased by any thing 
that tends to deteriorate the general health, as the injurious effects of 
improper food, bad air, &c, &c. Delicate children suffer more con- 
stantly than the robust, their dentition being tedious ; and in them, 
bowel complaints, with wasting, frequently attend. Any complaint, 
in short, to which a predisposition may have existed, is likely now 
to be developed : and any disease contracted at this time (as measles, 
pertussis, &c), is attended with additional danger. 

Dentition is, however, no longer regarded by the well-informed 
practitioner, as a universal source of infantile disease ; and we shall 
treat only of such complaints as are to be traced distinctly to this 
source, resting satisfied with a general notice of its incidental relation 
to other maladies. 

Many of the symptoms caused by dentition are truly nervous ; 
but inflammatory aflections do often arise from, or are complicated 
with it. The local symptoms of irritation in the gums are at times 
severe : and here, in truth, lies the origin of all the others. There 
may be much swelling, heat, redness, and pain in the gums, which 
will be so tender as not to tolerate the slightest pressure. This most 
usually occurs on the first irritation, during the "breeding of the 
teeth ;" and the redness of the whole gum is then often very intense. 
At a later period, when the tooth is coming forward, the sensibility 
undergoes a modification, and pressure gives ease rather than uneasi- 
ness, the redness being now confined to the base of the gum, the sur- 
14* 



16 o DENTITION. 

face being white, or looking like a vesicle stretched over the tooth. 
Aphtha? or ulceration may be present, and the cervical, or more 
usually the salivary glands, enlarged and tender, accompanied by a 
very profuse flow of saliva. The determination of blood may extend 
further, and engage the head, which will be hot and heavy ; the 
cheeks red and swollen ; and the eyes suffused and watery. Great 
thirst, heat of skin, restlessness and alternate heaviness, with disturbed 
sleep, or sudden startings therefrom, now attend. This symptomatic 
fever is remarkable for its suddenness and variableness, often recur- 
ring and remitting within a few hours. Distant organs soon become 
implicated in a marked manner, and suffer sympathetically, either 
from inflammatory disease, or mere nervous disturbance. 

Acute inflammatory affections, wholly independent of dentition, 
may occur during this process, which predisposes to them ; but no 
doubt can exist that many such affections are directly connected 
therewith, as they rapidly subside when the irritation in the gums is 
mitigated, but are little relieved by any means, so long as this subsists 
undiminished. The treatment of such cases requires no modification 
beyond the necessity for paying primary attention to the state of the 
gums. 

Nervous disturbance of various organs still more frequently arises 
in connection with dentition ; and upon a correct diagnosis between 
these and the inflammatory affections, will depend much of our suc- 
cess in practice. 

Some of these secondary affections appear to be rather of a salu- 
tary character, as if efforts of nature to afford relief by counter-irrita- 
tion or derivation, as we see in the abundant flow of saliva, and lax 
state of bowels, so constantly attendant upon teething. Suddenly 
suppressing these is certainly dangerous ; and so long as they retain 
their merely sympathetic character, little should be done to interfere ; 
but we are by no means to fall into the popular error, that treatment 
for such is never to be adopted, and so allow children to die of purg- 
ing or vomiting, because they are getting their teeth. The mucous 
membrane is the tract most liable to suffer from these secondary 
affections, and the gastro-intestinal mucous membrane is that most 
frequently affected. The brain and nerves, however ; the lungs, the 
skin, and the lymphatic glands, are all subject to this irritative dis- 
turbance; and we remark that occasionally the urine becomes pale 
and copious, as it is observed to do in the nervous affections of adults. 
It is at times, however, scanty and turbid, and passed with difficulty 
when fever is high and the bowels, in particular, much disordered; 
or a purulent discharge may take place from the urethra, and great 
pain attend the passage of the urine. 

Symptomatic disturbance of the brain or nerves often induces 
sleeplessness, or very uneasy slumbers, with startings and sudden 
awakenings out of sleep, the child screaming and looking frightened. 
If there be grinding of the teeth, with tremor or rapid motions of the 
lips, convulsions are likely to follow, particularly if the fever be high, 
and bowels costive. These symptoms may depend on mere nervous 
excitement, or arise from congestion, or be connected with derange- 



DENTITION. !63 

ment of the digestive organs. Indeed in all severe affections of the 
bowels, the brain is certain, sooner or later, to participate : but the 
brain itself may be the seat of disorder without the condition of the 
bowels, becoming necessarily disturbed. The convulsive movements 
are often confined to mere twitchings of spasmodic motions of the 
face, eyes, and arms, and in such cases are not so dangerous as is 
commonly thought. In no case, however, are they to be neglected ; 
for great danger attends when they become general, violent, and 
frequent. Death may take place suddenly, as if by apoplexy ; or 
an incurable paralysis be the result, as we have more than once 
witnessed. In these as well as other instances of cerebral affections 
in the child, we should bear in mind that a state of exhaustion, as 
well as plethora, may give rise to the symptoms ; and search out the 
cause accordingly. 

An affection of the hands and feet has been described by Dr. Kellie, 
of Leith as connected with dentition, in which a spastic contraction 
of the flexors of the thumbs and toes is a principal character ; but a 
peculiar swelling of these parts also mentioned by him, shows it to 
be an affection before described by Underwood. This swelling arises 
suddenly, is of a mottled or purplish hue, very round and elevated, 
and cooler than the surrounding skin. It may last some weeks, but 
usually terminates favourably in a few days, ceasing spontaneously 
when the tooth appears. Of the spasmodic affections connected with 
dentition, those of the respiratory organs are especially formidable, 
as spasm of the glottis, &c, &c. The most frequent of these, however, 
is the dry, nervous, irritative cough, that so often attends dentition, 
and which is sure to be aggravated by any derangement of the 
bowels. This, like all the other symptoms dependant on irritation in 
the gums, will be mitigated, or at once removed, by the liberation of 
the tooth. 

Diseases of the skin often occur during dentition, being popularly 
denominated " tooth rashes," but we should not look upon such as 
arising directly therefrom, unless they appear or disappear in relation 
to the condition of the tooth, which they do occasionally in a remarka- 
ble manner. 

Affections of the lymphatic glands appear to arise rather in conse- 
quence of the debility induced by teething, than directly from the 
irritation caused thereby. Guersent, however, appears to look upon 
the early and rapid development of the teeth as occasionally the 
cause of tubercle and such affections ; a view nearly the reverse of 
that of Gardien, who considered very early dentition as caused by a 
scrofulous diathesis. To this view we ourselves subscribe ; having 
observed that not only is the appearance of the teeth likely to be 
precocious in scrofulous infants, but that this process is mostly 
unfavourable in such ; especially when the strumous diathesis is marked 
by external signs, as deficiency of ossification in the bones of the 
head, chronic hydrocephalus, &c, &c, — so much is dentition influ- 
enced by the congenital condition of the constitution. 

By far the most frequent of the symptomatic affections attendant 
upon teething are those of the stomach and bowels, which therefore 



164 DENTITION. 

we have reserved for last. Purging or vomiting often attends denti- 
tion. The purging is characterized by being unaccompanied by pain 
on pressure ; the tongue is moist and white, not red or dry ; the 
appetite remains unimpaired, nor does the child lose flesh. Acidity, 
however, and flatulency, with griping, frequently attend, when the 
stools are green, and smell sour, as does also the breath. Vomiting 
is often conjoined with purging, during dentition, and may be, like 
it, merely symptomatic ; but when they are carried to a great degree, 
this combination is a most formidable one, and often proves fatal. M. 
Cruveilhier has described a disease of this kind, as also M. Guersent 
(though with some difference) ; but we cannot agree with them in 
regarding it as necessarily connected with dentition, though often 
appearing at this period, as we have seen it prevail at times quite as 
an epidemic, and must regard it, with Dr. Joy,* as a species of cholera 
morbus. This disease, which German writers denominate gastro- 
malacia infantum, requires very decisive treatment, and will be 
noticed in the proper place (see Cholera Infantum) ; but we should 
be cautious in interfering with the slight purging and vomiting that 
so often attend dentition, so long as the child's strength remains 
unimpaired, and no signs of inflammation make their appearance. 

Treatment. — The management of the morbid conditions connected 
with dentition is in nothing peculiar, beyond what concerns the local 
treatment of the teeth and gums, which we now proceed to consider, 
— leaving the diseases in question to be treated of each under its 
proper head. 

When dentition proceeds favourably, as a natural process, little 
interference is required. Generally speaking, the child should be 
kept calm and cool (more especially the head), and much in the open 
air ; the bowels rather free ; and great care taken to avoid overload- 
ing the stomach, or giving stimulating food. And this precaution is 
as important to attend to with respect to the nurse as the infant. 
Exposure to cold air should be avoided, inflammatory affections 
being very liable to occur at this period. As dentition advances, or 
on its completion, the child usually suffers somewhat in its general 
strength, and will require improvement of diet, as the occasional use 
of a little weak chicken broth, &c, &c. ; the object being to keep the 
system at a just medium. Dr. John Clarke especially recommends 
sponging the head daily with cold water. So long as no particular 
irritation or suffering exists in the gums, the less they are interfered 
with the better. Something, however, will always be done, and it 
is well to understand what that should be. One of the first symp- 
toms of teething is tenderness of the gums, which are often so sensi- 
tive as not to tolerate any pressure ; the child attempts to put things 
into its mouth, but appears to be hurt ; and, at this time, such should 
not be supplied. Gentle friction with the nurse's finger soothes the 
gums most : and if they are very hot, the finger may be previously 
dipped in cold water, or other fluid, that has been sweetened. 

* f ee " ^ entition >" Cyclopedia of Practical Medicine — one of many excellent 
articles by Dr. Joy, to which we shall have occasion to refer. 



DENTITION. 16 5 

At a more advanced stage, as the tooth is coming forward, the 
mode of sensibility seems altered, and pressure on the gums gives 
satisfaction, so that the presence of hard substances is enjoyed. This 
is the period for corals, ivory rings, &c, &c. The latter, from their 
shape, are less liable to hurt than the former, and should therefore 
be preferred. Some particular virtues have long been ascribed to a 
ring of gold ; but, even if not too expensive for common use (it should 
be large, to be safe), the reasons assigned for its utility are unfounded ; 
as we cannot agree with Mason Good, that because ptyalism followed 
friction of the gums with powder of gold, in the experiments of Dr. 
Chrestien, of Montpelier, such effects are to ensue from the use of 
the metal in form of a ring. The production of an increased flow of 
saliva is attempted, in some parts of Germany, by the use of little 
bags of spice and sugar ; while in France they dip any substance used 
in honey, or sweet decoction of barley, as being relaxant to the gums. 
Such practices succeed in occupying or soothing the child ; but mis- 
chief arises from stimulating or overloading the stomach and bowels 
with sweets or spices. A good and simple plan is, to allow a child 
the use of a small wax candle, or occasionally a stick of liquorice 
root ; but, in truth, a crust of bread answers all useful purposes. 
When much local irritation prevails, and the gums become very hot, 
tender, and swollen, the tooth may be obviously on its way, to pro- 
trude. The local treatment is now the most important point, often 
removing the necessity for any other ; and without it, all other means 
may prove ineffectual. To relieve the tension, and remove the irri- 
tation, is our object, and the gums should be scarified ; but there are 
two purposes for which this may be done, and according to which 
the operation will vary. We may wish merely to draw blood, which 
will be done by scarifying the gum freely, but not deeply ; this may 
be advisable in the first stage of irritation, and before the tooth appears 
to be coming forwards. Such practice, however, is not often required ; 
and we should never omit to explain our object, as a tooth is always 
expected to appear soon after the gums are scarified, and in this 
instance disappointment only would ensue. When our object is to 
open the gum so as to free the tooth, our incision must be made freely 
and firmly through the gum and capsule, until we feel the instrument 
grate upon the tooth. If it be a molar tooth, the incision should be 
crucial, or double, so as to enclose a small flap, which some advise 
to be cut out, but this is seldom required. The child's head should 
be held firmly by an assistant, while the operator stands before or 
behind, according as the tooth is in the under or upper jaw, and with 
the fore-fingers of his left hand keeps the tongue and cheeks out of 
the way, while he makes his incision longitudinally with a gum- 
fleam.* The instrument should be sharp and clean, and no fear need 

* It is often difficult to make a child open its mouth, and it may be well to men- 
tion the plan we have found most convenient: by pressing firmly with the finger 
and thumb upon each cheek, we never fail to separate the jaws ; and, in children 
who have already cut the front teeth, we can keep the mouth open, and prevent our 



- 66 DENTITION. 

be entertained of ulceration. The bleeding that follows always does 
good, nor need apprehension be entertained about hemorrhage. The 
operation is scarcely attended with pain, and is followed by quick 
relief; but the tooth will not always immediately appear, even though 
the capsule be opened. A repetition of the operation is not unfre- 
quently required ; but when the local distress is relieved, the mere 
absence of the tooth is not a sufficient reason for its renewal. No 
one need suppose, that if a cicatrix be formed, it tends to retard the 
progress of the tooth, by its callosity, — the fact being, that newly 
cicatrised parts are those most easily absorbed. This operation 
should never be omitted when the local irritation runs high ; and its 
prompt employment will always mitigate, and often remove, any 
attendant symptoms, particularly if merely sympathetic, or of the 
nervous class ; even when inflammatory, relief is afforded, and the 
usual treatment will seldom require to be pushed so far afterwards 
as in ordinary cases of like inflammation. 

II. SECOND SET, OR PERMANENT TEETH. 

The first set of teeth begin to fall or be shed at about seven years 
of age, and are replaced by the second or permanent set, the whole 
of which are, by this time, more or less ossified, with the exception 
of the dentes sapientise, whose ossification does not, in general, com- 
mence until about the ninth year. This process of changing the 
teeth occupies from five to six years in its completion ; but is very 
variable both as to the time of its commencement and period of dura- 
tion, much irregularity altogether prevailing as to the age at which 
the different permanent teeth are cut. They may begin to appear" so 
early as five years old or not until eight, or eight and a half, and the 
termination of the process, or appearance of the third molares (dentes 
sapientiae), may be delayed to the seventeenth or nineteenth year. 
With the second as first set the teeth in the lower jaw generally pre- 
cede those of the upper ; and the first permanent molares frequently 
pierce the gum before the loss of the temporary central incisores — 
their appearance being in fact an indication of the approaching 
change. 

The immediate cause of this change in the milk teeth seems to be 
(according to M. Serres), the obliteration of the artery of these teeth, 
and its canal, which takes place about the seventh year, more or less 
completely, when the fangs and sockets become absorbed. The 
ascent of the second set contributes somewhat to the general process, 
by destroying the nerves and vessels, but does not do so directly, as 
might be supposed ; for the absorption of the root seldom if "ever 
commences at its extremity, but generally at some distance from it, 

fingers from being bitten, by turning a portion of the under lip into the mouth, be- 
tween their teeth and our own thumb. 

Dr. Blake recommends the incision to be made towards the external plate of the 
alveolar processes, so as to avoid injuring the connecting membranes and sacs of 
the permanent teeth. See Blake's Essay on the Teeth, p. 177. 



* 



DISEASES OF THE DIGESTIVE ORGANS. 167 

often near the neck; while the permanent teeth have separate 
sockets of their own, and in consequence of the prolongation of the 
jaw-bones, which takes place at this age, do not lie immediately under 
the shedding teeth that correspond. Yet the presence, though not 
the pressure, of the new tooth is necessary, for in cases in which the 
temporary teeth remain, the corresponding permanent ones are found 
not to have been formed. In the foetus, we see the germs of the 
greater number of the second set lying behind or below the first. 

The increase in length and perfection in the articulation of the 
jaws makes a great difference between the adult and the infant in 
the powers of motion as well as in the form of the jaw. In the child 
the shape of the jaw-bones, anterior to the tubercle in the upper, and 
ascending plate in the lower jaw, is semicircular; and the articula- 
tion very imperfect (before the teeth are produced), the glenoid 
cavity little exceeding the condyle in size, and the articular eminence 
not yet being formed ; the centre of motion being in fact in the con- 
dyle, and the movements restricted to simple depression and elevation 
with hardly any approach to rotation — all id truth, that is necessary 
to the infant for the mastication of its simple food. In the growth 
of the jaw, the elongation takes place principally between the second 
bicuspides and the tubercle in the upper jaw, and the same teeth and 
the ascending plate in the lower ; in the situation of the permanent 
molares or additional teeth, and posterior to the temporary ones. 

The cutting of the second set of teeth is seldom attended with dis- 
tress ; and when local irritation does occur, it is little felt by the 
constitution, which has lost by this time its acute sensibility ; but 
occasionally much local suffering and consequent constitutional dis- 
tress, does attend, and the free use of the gum lancet is required. 
When the teeth come up very irregularly, and press against those 
before them, or protrude by their side, so that some of the same teeth 
of both sets are apparent together, extraction of one or more of the 
first set will become necessary ; but this matter belongs to the pro- 
vince of dental surgery, — as also the use of dentifrices, &c, which, 
however, children should be early taught to employ — at least, they 
should be instructed to brush their teeth once or twice each day, with 
a soft tooth-brush and water. 



CHAPTER VIII. 

DISEASES OF THE DIGESTIVE ORGANS. 
I. GENERAL OBSERVATIONS. 

The gastro-intestinal mucous membrane is, in particular, subject 
to disease even in the youngest infant, being easily irritated and often 
inflamed ; but an opposite state, or one of relaxation or mere debility, 



.•I DISEASES OF THE DIGESTIVE ORGANS. 

will be found not un frequently to be present, whether as a sequel to 
morbid conditions, or existing independently thereof. The 
mucous membrane may be affected through its whole tract ; or what 
is more usual, in one part only, as the mouth or stomach ; but fre- 
quently two or more portions are at the same time the seat of disease, 
gastto-enteritis being much more frequently seen than simple gas- 
tritis ; and of these parts some, as the small intestines, are much more 
liable to be attacked than others. 

Again, different structures may be separately engaged, as the 
serous or mucous membrane, or merely the mucous glands ; and 
hence will vary the name of the disease according to its seat, or the 
nature of the affection. 

Inflammatory affections are very common ; and the inflammation 
may be simply erythematous, or may lead to ulceration, exudation, 
softening, or gangrene. 

The ulceration may be of a common kind, or what is more usual, 
of an aphthous character; and exudation may take place as a con- 
sequence of this ulceration, or independently of it ; inflammation of 
mucous membranes having a peculiar tendency to the formation of 
such deposits in the child. Exudations upon the mucous membrane 
are of two distinct characters, either white and soft, being made up 
of the crusts of aphthous ulceration, or consisting of a peculiar secretion 
resembling milk or curd, and said to result from a particular form of in- 
flammation; or the exudation maybe firm and tenacious, truly consist- 
ing of an effusion of lymph. Any of these forms of disease may end in 
gangrene, or from the commencement show a disposition thereto ; but 
this is more likely to occur in ulcerative than inflammatory affections, 
particularly of the mouth and throat. 

In the mouths of children, in particular, we may witness every one 
of these affections of the mucous membrane ; and most of them may 
be seen in any tract of the intestinal canal. But some are much 
more liable to occur in certain regions than others, as aphthous ulcer- 
ation in the mouth, follicular ulceration in the ileum, and exudations 
in the pharynx or fauces, while a few are very rare in any. 

The mucous membrane of the mouth in children shows a disposi- 
tion to disease from the earliest age, and may be seen in a state of 
congestion at birth, or of inflammation almost immediately after. 
Ulceration, or exudation, are common consequences ; and are always 
attended with a degree of danger, even in the mildest cases, from 
their liability to spread, and so pass into the digestive tube, or en- 
croach on the air-passages. So long as the disease is confined to the 
mouth, even in severe cases, little constitutional disturbance is per- 
ceived if the infant be young. But these affections are seldom merely 
local, being usually complicated with gastric or intestinal disease, or 
symptomatic thereof. Hence constitutional treatment, particularly as 
regards the state of the bowels, is never to be neglected ; but atten- 
tion must not be confined to this alone. Not less important is the 
local treatment ; a prime source of danger, in such affections being 
(as already noticed) their tendency to spread. Hence no time is to 
be lost before trying to arrest their progress by topical applications. 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 159 



II. AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 

Inflammation of the mucous membrane of the mouth — Stoma- 
titis — is not an uncommon disease among children; and maybe 
brought on by cold, stimulating or improper food, the too frequent 
use of the sucking -bottle, &c, &c, or may be symptomatic of a simi- 
lar condition of the stomach, or other part of the intestinal canal. 

The symptoms are heat, and redness of the lining membrane of 
the mouth, to a greater or less extent. The tongue and mouth are 
often dry ; the lips may be swelled and excoriated, or surrounded by 
an eruption ; and when the disease is protracted, and the infant but 
a few months old, a profuse flow of saliva occasionally attends. But 
there is seldom any appreciable fever, unless the infant has reached 
the fifth or sixth month, when such is usually present. 

Inflammation of the mouth, when slight and uncomplicated, is 
attended with little danger, and usually yields to mild emollient 
applications, such as mucilage of gum, decoction of barley, or, better, 
the linctus recommended by Boerhaave, and consisting of equal parts 
of mucilage of gum, white of egg, and simple syrup ; attention being 
at the same time paid to the state of the bowels, and care taken to 
remove any source of irritation, as in the nature of the food, the 
mode of feeding, &c, &c. 

When complicated with intestinal disease, or symptomatic thereof, 
the case becomes serious, and the principal attention must be paid to 
the more dangerous disorder. When a tendency to run into ulcera- 
tion, or sloughing, and to spread, is manifested, local applications, 
calculated to alter the morbid action, or arrest its progress, must be 
adopted ; as recommended in the following section. 

Inflammation of the mouth with ulceration — Ul§erous Stoma- 
titis. — Inflammation, if intense or protracted, soon leads to ulcera- 
tion, especially in children who are mismanaged, or placed in unfa- 
vourable situations, and whose general health is in consequence 
deteriorated. These ulcerations may be of a common character, or, 
what is more usual, of that peculiar form denominated aphthous, 
and long known under the general appellation of thrush. 

Symptoms. — The common ulcer is usually large and irregular in 
shape ; it is covered with a white or yellowish slough, and sur- 
rounded by much redness. These ulcers are seldom numerous — 
often single, and are situated on the inside of the cheek, the roof 
of the mouth, or may be found on the tongue. We have occasionally 
seen in infants at the breast, an ulceration of the gums of a very 
acute character; but which seldom occurs after the first year. The 
gum appears spongy, vascular, or of a purplish hue ; and the ulcera- 
tion often runs deep, being disposed to bleed, and assuming a green- 
ish or ash colour; but it is not liable to slough. It occurs usually 
about the period of first dentition. Much local irritation attends 
these ulcerations of the mouth, with fever, which occasionally runs 
high, and is accompanied by great restlessness ; the digestive organs 
being in particular deranged. 
15 



170 DISEASES OF THE DIGESTIVE ORGANS. 

Treatment. — In mild cases, it will be sufficient to touch the 
ulcerated surface occasionally with a linctus composed of borax or 
alum, from gr. v. to gr. x., dissolved in an ounce of honey of roses ; 
care being at the same time taken to regulate the state of the bowels, 
supply light but nutritious food, and expose the child freely to the 
fresh air. In severer cases, it may be necessary to have recourse to 
one or two applications of the nitrate of silver, lightly touching the 
ulcerated surface therewith ; but the local remedy from which we 
have uniformly derived most benefit in this and other forms of ulcera- 
tion of the mouth, even when the surrounding inflammation runs 
high, is the sulphate of copper. A linctus, consisting of ten grains 
of this salt recently dissolved in an ounce of honey should be applied 
two or three times a day by means of a camel-hair pencil. When the 
child is very irritable or restless, an anodyne will become necessary, 
and tonics, particularly quinine, must be had recourse to in protracted 
cases, or stimulants, as ammonia, when the strength begins to fail. 
The state of the bowels will of course be attended to, and the occa- 
sional exhibition of an emetic when the breath is foul and efforts 
made to vomit will be found useful. 

Aphthous ulceration — Vesicular Stomatitis. — The form of 
ulceration most commonly seen in the mouths of children is the 
small circular white ulcer, called aphtha, and which occurs with 
them in a truly idiopathic form (especially at the period of teething, 
being seldom seen before that time), and is not necessarily connected 
with any constitutional or other cause, as is always the case when 
they appear in adults. 

Most generally, however, aphthae arise in connexion with derange- 
ment of the digestive organs ; and are hence oftenest seen in children 
artificially fed, and whose food not being properly digested, becomes 
a source of irritation to the stomach and bowels. We also see 
aphthae appearing in the mouths of children sympathetically with 
disorder of some part of the intestinal canal, which is itself similarly 
affected. Thus, in the advanced stages of gastro-intestinal disease, 
aphthae may spread from the stomach to the mouth, or co-exist at 
the same time, in two distant parts, being visible at the verge of the 
anus as well as inside the lips — but this does not necessarily imply 
that the whole intestinal tract is occupied by the disease. 

When situated far back in the mouth or on the pharynx, aphthae 
are liable to spread downwards, either into the oesophagus or air- 
passages ; the former is most likely to occur ; but it is only in chil- 
dren much broken in health, or placed in crowded and unwholesome 
situations, that such in general takes place. 

Under these circumstances many children may be found affected 
with the disease at the same time ; aphthae appearing to spread epi- 
demically ; they are also capable of being communicated by direct 
contact to a similar structure, as true aphthae have been taken by 
kissing the lips of an infant affected with the disease ; but the nipple 
of the nurse does not seem to be affected with this form of ulceration, 
though often made sore or excoriated, from suckling an infant affected 
xvith the disease. 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 171 

Symptoms. — An inflammatory condition of the mucous membrane 
of the mouth does not appear to be a necessary antecedent to the 
appearance of aphthae, neither is the aphthous ulcer always sur- 
rounded by a red or inflammatory border. The mouth, however, is 
usually hot, and the child fretful and uneasy. The appearance of 
the ulcer is that of a small white spot or speck, occurring singly or 
in clusters, on some part of the mucous membrane of the mouth 
or throat. When single or few, aphthae are usually found on the 
inside of the lower lip, on the gums or on the tongue. When numerous 
or confluent, the inside of the cheek is often quite covered with them, 
or they extend backwards to the fauces. In these cases the aphthae 
become covered with a continuous crust or coating of a whitish hue ; 
but on this being removed, or becoming detached, the ulcerated points 
are visible beneath: and the secretion by which they had been 
covered, is quickly renewed. The whole process takes three or four 
days for its completion, from the bursting of the vesicle to the forma- 
tion of the crust and the cicatrization ; but a succession of single 
aphthae may continue for several days or even weeks. When two 
or more run together, or become confluent, they are much more slow 
to cicatrize ; and altogether an attack of aphthae usually runs a course 
of eight or ten days. The crusts, on being swallowed, become a 
source of irritation to the stomach and bowels, and it is thought that 
the disease itself may be thus propagated to these parts. 

The bowels are usually deranged when aphthae are present, being 
costive, and the secretions vitiated ; or frequently diarrhoea attends, 
and acidity of the stomach is present : but there is not in general 
much accompanying fever, especially if the child be very young. 
Difficulty of mastication or deglutition may attend, the child being 
unable to suck, and so becoming restless and peevish from hunger ; 
but we should specially note any alteration in the tone of the- voice, 
peculiarity of breathing, or the occurrence of cough. When aphthae 
present a yellowish or dark coloured appearance, we should be care- 
ful to examine whether this be caused merely by their being tinged 
with bile or blood, or is an indication of their assuming an unhealthy 
or gangrenous character. Such may be apprehended when we see, 
in very delicate children or protracted cases, crusts of this description 
succeeding to the white appearance at first presented. 

When aphthae do become gangrenous, the surface grows brown, 
being covered with a hard eschar, or one soft and pultaceous ; but 
when detached, the part beneath appears very red or granulated. 
The edges of the ulcer assume a torn, soft, or burned appearance, 
and the surrounding parts are soft and easily depressed, being swollen, 
and of a violet hue. As the disease advances, the mouth hangs open, 
allowing the saliva to escape, and a fetid odour usually attends. 
This condition is most liable to occur where aphthae are situated at 
the back of the fauces ; and seems to constitute that form of the com- 
plaint, known of old by the name of the black thrush, but which is 
not often witnessed except among the most wretched of the children 
of the poor. 

Diagnosis and Prognosis. — Aphthae are particularly character- 



172 DISEASES OF THE DIGESTIVE ORGANS. 

ised by their small size, circular shape and white colour, appearing 
like small white round dots or specks on the inside of the mouth, and 
leaving a slightly depressed or ulcerated spot on the removal of this 
white covering or crust. So long as they retain this appearance, not 
showing any disposition rapidly to spread, nor the child's strength 
in any remarkable manner giving way, no apprehension need be 
entertained respecting the presence of aphthae, which are not attended 
with danger in themselves, even though numerous or of long stand- 
ing, though they may prove troublesome from liability to repeated 
attacks ; but when they show a disposition to alter their appearance, 
assuming any of the characters already pointed out as indicative of 
their taking on an unhealthy action, or when they proceed to spread 
along the pharynx, much danger is to be apprehended. In the first 
case we have not merely to dread the occurrence of gangrene, but 
must look upon the alteration in the appearance of the ulcers, espe- 
cially when occurring in the advanced stage of intestinal disease 
and accompanied by prostration of strength, as indicating a state of 
constitution in which recovery can hardly be looked for. When 
aphthae occur symptomatically, or during intestinal disease, they 
appear more on the fauces than in the idiopathic variety, and are in 
general an unfavourable symptom, but not necessarily a dangerous 
one, so long as they retain their healthy aspect, and the child's strength 
holds up. The extension of aphthae down the oesophagus, though a 
serious symptom, is of little moment, compared with the danger that 
attends the extension of the disease to the air-passages. When the 
child's voice becomes hoarse or indistinct, the breathing stridulous 
or spasmodic, with fits of suffocation and cough, immediate danger 
threatens, if indeed the case be not hopeless ; for those who have 
not witnessed it, could scarcely credit the small amount of ulceration 
that seems capable of destroying life, if once aphthae pass, or even 
reach, the rima glottidis. 

Pathology. — Aphthae in general are seen to originate in an erup- 
tion of small, white vesicles, filled with a gelatinous or puriform 
fluid, but unless watched from the first, the vesicles may be over- 
looked. Ulceration succeeds, or a crust is formed of a white, pultaee- 
ous matter, consisting in the first instance of the collapsed cuticle left 
after the bursting of the vesicle, and then of a thin layer of lymph or 
concrete pus, or even of a slight slough, which leaves, on being 
removed, an ulcerated spot beneath. M. Billard, however, represents 
aphthae as truly an ulceration of the muciparous glands, or follicles, 
which, becoming inflamed, soften in the centre, and ulcerate. But, 
as Dr. Benson justly observes in his valuable lectures (see Medical 
Press, vol. v.), " the superficial character of an aphthous ulcer is 
very different from the deep set ulcer of a mucous gland." 

Treatment. — When aphthae are merely a local affection, they may 
be often quickly removed by local means alone ; but in most instances 
attention must be paid to the general state of health, particularly the 
condition of the bowels; and a mild laxative will in some cases at 
once remove the disease. When the bowels are merely costive, a 
dose of castor oil will be sufficient for this purpose, but if acidity of 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 173 

the stomach, or derangement of the secretions, be in addition present, 
we must have recourse to the pulv. rhei et magnesise, or the pulv. 
rhei comp., as advised at pp. 126, 127. We should be careful, how- 
ever, to avoid irritating the bowels or stomach by the use of purga- 
tives or emetics, although an emetic may occasionally be serviceable 
at the commencement of the disease ; but when of long standing 
there is risk of adding to the irritation already going on in the mucous 
membrane. When diarrhoea occurs, or the aphthae appear during 
its presence, the chief attention must be paid to allay the irritable 
state of the bowels, and to support the strength when this begins to 
fail ; particularly when the aphthae assume an unhealthy aspect. 
Small doses of the hydrargyrum cum creta, with Dover's powder, 
may in the first instance be employed, and then the compound powder 
of chalk, with or without opium, according to the urgency of the 
symptoms. Regulation of diet or changing the nurse, attention to 
cleanliness, the occasional use of the warm bath, change of air, or at 
least free exposure to the fresh air, are essential in protracted cases ; 
or when aphthae are prone to recur. When the ulcers present an 
unhealthy aspect, we must early have recourse to the quinine mix- 
ture, and in the more advanced stages, the free use of ammonia will 
be found specially serviceable. 

The local applications to be used in the treatment of aphthae differ 
little from those recommended for the treatment of simple ulcerations 
of the mouth. The solution of borax in the first instance, and that of 
alum subsequently, will be found most serviceable — when the aphthae 
are few or very irritable, touching them lightly with nitrate of silver, 
will best dispose them to heal, and lessen their sensibility. In the 
more protracted cases we have derived signal benefit from the linctus 
of sulphate of copper. A solution of chloride of soda answers welL 
to correct the fetor when the ulcers show an unhealthy aspect ; but 
should sloughing actually occur, we must have recourse to the more 
decided measures required for gangrenous ulceration. 

Inflammation ivith exudation — soft — white — muguet or millet. 
— We occasionally see in young infants an inflammation of the mouth 
more or less extensive, but not appearing to be of an intense kind, 
which is attended by an exudation of a soft, white, cream-like or curdy 
substance, being disposed in specks or patches, or even covering the 
whole surface, (particularly on the palate or base of the tongue,) so 
as to give the appearance of the child's mouth being lined with 
cream or curd; on removing this substance, the membrane beneath 
is found red and shining, but unbroken, the secretion being external 
to the epithelium, and not the result of ulceration as in aphthae. M. 
Billard considers that in this instance the papillae of the mucous 
membrane in particular are the seat of this peculiar form of inflam- 
mation, which chiefly occurs in young infants antecedent to the time 
of teething, and may be even seen in those but a few days old. 
Our experience is, decidedly, opposed to his, however, when he says 
that aphthous ulceration is never seen in infants until the period of 
dentition. Aphthae may appear at the same time with muguet ; but 
we cannot agree with VVillan in regarding the latter as a vesicular 
15* 



174 



DISEASES OF THE DIGESTIVE ORGANS, 



disease. Neither do we coincide with Billard in considering the 
exudation in muguet as merely concrete mucus, but rather as some 
peculiar deposition, intermediate in consistence between the soft 
crusts of aphtha? and the true tenacious lymph in diphtherite. 

This morbid secretion, to which the French have applied the term 
muguet, and to which perhaps belongs the English appellation white 
thrush, is seldom seen in this country, but appears, at all times, to 
prevail in the French hospitals where infants are crowded together 
and fed principally by hand. It is not, however, looked upon there 
as being contagious, even by direct contact, children being said to 
drink, with impunity, from the same cup with those affected by the 
disease. We have occasionally seen it in infants who were very 
delicate or ill fed ; and in one or two instances to such an extent that 
the white fluid exuded from the nostrils. The mucous membrane 
near the anus also may present a similar deposit ; or it may appear 
in the stools, for muguet, like aphthae, occasionally occurs in the tract 
of the intestinal canal, but much more rarely. 

Like aphthae, it may extend down the oesophagus or into the air- 
passages ; but it is not a disease attended with much danger ; neither 
have we any directions to give as to its treatment differing from 
those already advised for the management of aphthae ; except, per- 
haps, that the alum solution, in particular, seemed to us to exercise 
an effectual control in checking the tendency to the renewal of the 
secretion.* 

Inflammation ivith exudation — firm — tenacious — lymph — 
Angina membranacea — Diphtherite. — An inflammatory affection, 
intense in degree, and peculiar in kind, being attended by a pellicular 
exudation, may be seen affecting the pharynx, soft palate, or tonsils in 
children. This disease is not confined to children, but is seen more 
frequently in them than in adults, particularly in very young children 
that are unwholesomely fed and placed in low, damp situations. 
Under such circumstances, the disease occasionally occurs in the form 
of an epidemic, and appears to be highly contagious ; but is not a 
disorder commonly met with. It is very necessary to distinguish true 
diphtherite from other affections of the same parts with which it is 
confounded, as our chief chance of success depends on an early dis- 
crimination of the nature of the case, so as at once to apply remedies 
to arrest its progress. True diphtherite (as its etymology implies) is 
" a pellicular inflammation,"! or one attended with a membranous 
exudation; but unaccompanied by any breach of surface or ulcera- 
tion. It is, however, liable to be attended with gangrene or slough- 

* We may here remark, that whatever applications be used in those affections 
of the mouth, orders should be given to have them laid on gently with a feather or 
camel-hair pencil, not rubbed in with a piece of linen, as attendants will be sure to 
do, if not warned against their rude propensity for scrubbing the child's mouth, by 
way of making it clean — a certain method for aggravating the disease or even 
causing ulcers to slough. [Note to 4th Edition.] 

t For a full account of this disease see Bretonneau's work : — Des inflammations 
speciales du tissu muqueux, et en particulier de la diphtherite, ou inflammation 
pelliculaire, connu sous le nom de croup, &c, &c. 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 175 

ing, and this constitutes a variety of the complaint differing from 
the more acute or highly inflammatory kind, in which this termina- 
tion need not be apprehended, and hence this source of danger is 
removed ; but in both forms, the tendency of the false membrane to 
spread and enter the air-passages, constitutes a special source of 
danger in this complaint. 

Symptoms. — These will vary according to the form of the com- 
plaint, and this seems to depend much on the class of persons attacked ; 
the affection of the throat assuming more or less of the acute inflam- 
matory character in children that are well fed and robust, while it 
quickly presents the gangrenous aspect in the feeble, ill-conditioned 
children of the poor. 

In the acute form, we find the mucous membrane of the fauces 
presenting at first a bright red colour ; then quickly becoming stud- 
ded with specks or patches of false membrane, seen on the posterior 
pharynx, the tonsils, or the velum. This will assume the appearance 
of a continuous layer of a thin, white and smooth, concrete substance, 
when the inflammation is of a severe form, or in still severer cases, 
the lymph is deposited in masses of a grey or yellowish colour, pre- 
senting an irregular surface and of a soft consistency, so as easily to 
be detached but being again soon renewed ; the palate and tonsils 
in addition to being highly inflamed, being considerably swelled, yet 
deglutition gives little uneasiness, and the throat is but slightly pain- 
ful. In very mild cases, the disease nearly resembles muguet, the 
lymph being so soft or pulpy that it can be marked by the finger like 
concrete mucus, and this variety is hence caWedpultacea or caseiform. 
The constitutional disturbance is not in general great ; the skin is 
warm, but the pulse though full is not quick. Far otherwise are the 
symptoms, both local and general, in the other form of the disease, 
when it assumes the malignant type and is presented to us as an epi- 
demic of a fearful and fatal nature. 

The invasion of this form of the disease is often slight or hardly 
perceptible, the throat giving no uneasiness at first, nor presenting, 
when examined, any very marked redness — soon, however, diffi- 
culty is experienced in deglutition, and often liquids are returned 
through the nostrils, before there is swelling of the throat to any de- 
gree sufficient to account for this occurrence. The submaxillary 
glands, however, often become swollen and painful. The lymph 
thrown out on the inflamed surface in this form of the complaint is 
soon presented in the shape of a dense and extensive membrane, of 
a yellowish grey, or a dirty ash colour, and, when tinged with blood, 
appears from its dark colour, and the dreadful fetor that often ac- 
companies the disease, to constitute an extensive gangrenous slough. 
On accurate examination, however, this appearance is found to be 
altogether deceptive, no sloughing or even softening of the mucous 
membrane taking place, as is plain on detaching the false membrane, 
which leaves the surface beneath without any of the peculiar odour 
of gangrene : the fetor, however intolerable, arising solely from the 
detached membrane, which seems to undergo a putrefactive process. 
This distinction is so absolutely insisted upon by French writers, that 
we might presume such must be always the case ; but undoubtedly 



|7Q DISEASES OF THE DIGESTIVE ORGANS. 

the mucous membrane itself does occasionally slough, being found of 
ft deep ash, or even black, colour, beneath the detached lymph, and 
coming away therewith, until the throat presents a hideous chasm. 
Blood frequently exudes from the lips and gums, or an acrimonious 
discharge from the nostrils ; and the membrane may be so exten- 
sively deposited as to reach to the nasal fossae themselves ; portions 
being occasionally discharged with the acrimonious secretion there- 
from. It is the extension of the membrane into the air-passages, 
however, that in a particular manner constitutes the danger of this 
form of diphtherite, and this is certain to occur, if the progress of the 
disease be not arrested, or the patient does not first fall a victim 
to the malignant fever that attends the complaint. 

From the very commencement of the attack, a great prostration 
of strength and disorder of the nervous system usually attend. The 
skin is cool or only moderately warm ; and the pulse, though not 
rapid, is feeble. The general powers soon begin to give way in 
many of the severer cases, and in some the powers of life rapidly sink ; 
the breathing becomes hurried, delirium is succeeded by stupor ; the 
pulse grows very soft and feeble ; the patient dying, often unexpect- 
edly, in a day or two ; or at times even within twenty-four hours 
after the first invasion of the disease. So rapid a catastrophe, how- 
ever, is not the ordinary course of the disease even in fatal cases. 
The strength may hold up, and death be protracted to the tenth or 
sixteenth day ; with deceitful intermissions, especially in children 
who may be playing about shortly before death; which, in such 
instances, will be found to be hastened by some sudden extension of 
disease to the trachea. It may not be until the fifth or sixth day that 
the disease begins to assume a serious aspect, the breath becoming 
foul and the lymph thick and dark coloured, while the pulse grows 
soft and compressible. The bowels now also begin to be in a par- 
ticular manner affected, there being griping, with thin, watery, brown- 
ish stools, though without bile ; and occasionally nausea, vomiting, 
and tenderness of the epigastrium ; which certainly take place when 
there is any extension of the disease to the stomach. The symptoms 
increase in severity, and about the tenth day signs of sloughing mani- 
fest themselves, and our worst fears are too generally realised. 

When the fatal result is more directly connected with the exten- 
sion of the false membrane into the air-passages, we find symptoms 
of suffocation present. There is indistinctness or hoarseness of the 
voice, and a cough, frequent, harsh, and of a croupy sound ; the 
breathing becomes laborious and often convulsive, while the nostrils 
dilate, and the veins of the neck swell. As the case proceeds, the 
efforts to carry on respiration grow more feeble and languid ; the face 
assumes a pallid hue, the eyes are sunk, the chest heaves, and as the 
powers of life subsides, the child dies comatose or convulsed. 

When the membrane extends down the bronchial tubes (as it occa- 
sionally does), the expectoration is limpid and mucous ; the respira- 
tion gives a mucous sound ; the dyspnoea increases ; and occasionally 
shreds of the false membrane are spat up ; or even portions moulded, 
as it were, in the air-tubes, and bearing their shape. 

The form in which the disease presents itself appears to depend 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. 177 

much on the class of persons attacked, or the situation in which it 
arises; the malignant form being that usually seen when the disease 
occurs in low, damp situations, and in the crowded habitations of the 
poor, among whose children it often spreads with frightful rapidity, 
attacking in particular those that are very young and weakly. The 
most robust children and best situated, however, are not safe from 
even this form of the disease, when spreading, as it does at such times, 
(generally during the spring months,) with the rapidity of an epide- 
mic, rather than merely as a contagious disease ; but in general, 
strong and healthy children suffer only from the acute form of the 
disease, which, if not severe in degree, is unattended with any par- 
ticular danger, as- the false membrane remains confined to the 
pharynx, without a disposition to spread farther down. 

Diagnosis and Prognosis. — The affections with which diphtherite 
is most likely to be confounded, are aphthous ulceration existing in 
the pharynx, the gangrenous sore throat, or muguet. It is not un- 
common to find aphthous ulceration in the situation described, denomi- 
nated diphtherite ; for with some every spreading ulceration at the 
back of the throat goes by this name ; yet, the distinction is at once 
obvious and easy, the ulcerated state of the mucous membrane, on 
removing the aphthous incrustation, distinguishing it from the merely 
inflamed condition of the same surface in diphtherite. Equally decisive 
is the distinction between gangrene of the throat, in which the 
mucous membrane is found in a state of slough or sphacelus, and that 
malignant form of diphtherite, in which this membrane, although it 
may be dark red or even livid in colour, is still found in a state of 
integrity on the removal of the putrid membrane. Even should the 
mucous membrane slough in diphtherite, the presence of the peculiar 
lymphy coating distinguishes it from simple gangrenous sore throat, 
in which, although spots of lymph may be deposited, no concretion 
takes place. The distinction between muguet and diphtherite is some- 
times not so easily to be made ; but the deposit in muguet com- 
mences in the mouth, and is not so continuous nor tenacious ; while 
the age of the child, and history and progress of the case, soon help 
us to a diagnosis. 

Our prognosis in this disease must be always guarded, and in 
particular we must take care not to be misled by the absence of any 
uneasiness in the throat in the first instance, but when diphtherite 
prevails, be particular in examining the fauces, the moment a child 
sickens or appears ill ; for in some instances the disease will be found 
to be decidedly established before any complaint has been made of 
the throat, and the worst form of the disease may commence in this 
insidious manner ; the malady being mGre dangerous when spreading 
as an epidemic than when occurring in isolated cases ; and also more 
fatal in very young children than in those more advanced. When 
the child is healthy, however, and the disease of the acute kind, but 
not severe in degree, there is no particular cause for alarm, for the 
thin white and smooth exudation does not in general show a dispo- 
sition to spread beyond the pharynx, and may be seen not uncom- 
monly as an accompaniment of scarlatina or measles. Even in the 



17S DISEASES OF THE DIGESTIVE ORGANS. 

still severer form, where the lymph is thrown out in masses, as 
already described, there is not a tendency to spread to the larynx, 
though the deposition at times appears on the oesophagus. In very 
acute cases of the most healthy form, however, the false membrane 
will spread into the larynx, if not early arrested ; and in some in- 
stances its formation seems to occur almost simultaneously in the air- 
passages and on the pharynx, the croupy symptoms appearing to 
co-exist with the appearance of the lymph on the fauces : such a 
case we need hardly say must be almost necessarily fatal. In favour- 
able cases, on the contrary, the lymph is occasionally absorbed even 
without being shed, growing gradually thinner, so that the red 
papillae begin to appear through it like a veil ; or the lymph, when 
detached in patches, (as it usually is after a few days,) is renewed in 
a much slighter form ; and in a few favoured cases, does not again 
reappear. In the malignant form of diphtherite we have a double 
source of danger, a fever of the typhoid type being added to the 
almost certain affection of the trachea, for unless arrested in its pro- 
gress, the false membrane uniformly descends into the air-passages 
in this form of the complaint, which constitutes one of the most fatal 
and fearful diseases to which the child is subject. We are happily, 
however, not left without resources even in this formidable disorder, 
and although our prognosis must always be unfavourable, the prompt 
application of remedial means exercises a decided control over the 
disease. Even after the air-passages have become engaged, re- 
covery seems in some cases to have been effected. 

Pathology. — Having noticed so fully the nature of the deposition 
in this disease, and the condition of the mucous membrane connected 
therewith, it only remains to observe, that on the post-mortem ex- 
amination, the false membrane has been found extensively deposited, 
covering not only the parts visible to the eye during life, but ex- 
tending in some instances along the oesophagus, even to the cardiac 
orifice of the stomach ; and almost uniformly occupying the trachea, 
to a greater or less extent ; the bronchial tubes even not being free 
from its presence. The membrane is a deposit of true lymph, though 
varying in appearance and consistency, according to "the nature of 
the case. Hence, this disease has been looked upon as identical with 
croup by Bretonneau ; and Guersent seconds him in this opinion, 
which is, however, obviously to confound two distinct diseases, and 
fall into a grave error in practice. 

Treatment. — Passing over, in the first instance, any notice of 
remedies commonly employed in inflammatory affections of the acute 
or malignant kind, we at once inquire are there any topical applica- 
tions that, locally applied, are capable of altering the morbid action 
going on, and so arresting the progress of the disease, or destroying 
the false membrane when formed ; or do we know of any constitu- 
tional remedy that would give hope of success even after the disease 
had extended beyond the pharynx. To both queries we are able to 
answer in the affirmative ; but more reliance is to be placed on the 
topical than general remedy ; and early recourse to either is essen- 
tial to success. On the very first appearance of the affection of the 



AFFECTIONS OF THE MOUTH, PHARYNX, ETC. I79 

throat, a strong solution of nitrate of silver (at least, gr. xx. to 3 i.) 
should be extensively applied by means of a camel-hair pencil, to 
the sound parts as well as those already affected, and repeated, to 
prevent renewal of the membrane, which, though it may be removed 
in the first instance, is still liable to recur. By this means the spread 
of the inflammation has been arrested, and the deposition of lymph 
checked, when the case was not of the worst form, and has been 
taken at the outset. We have seen a similar result attend the use of 
a saturated solution of sulphate of copper. In the more formidable 
form of the disease, or at a more advanced stage, however, a much 
more energetic application must be employed : and all agree in giving 
a preference to the application of the muriatic acid, undiluted, or 
mixed with one or two parts of honey. It is to be applied by means 
of a piece of sponge attached to the end of a probang, and pressed 
firmly against the inflamed part. By this means the membrane, even 
after it has become putrid, has been destroyed and detached, the acid 
occasionally requiring, however, to be applied a second or even third 
time ; this application exercising its influence specially in destroying 
the membrane, as the other does in preventing its formation. 

The administration of mercury so as to affect the system, is the 
constitutional mode of treatment which has been looked to for arrest- 
ing the disease, even after the membrane has spread. In very young 
children this result, however, can hardly be expected, but in the more 
grown the testimony in favour of this plan of treatment is so strong, 
that it should certainly not be left untried. When mercury has 
affected the system, we may look with confidence to an arrest of 
the progress of the disease towards the trachea, if not even to the 
staying of its course there, but the tendency to sloughing is not 
likely to be mitigated thereby, if not, indeed, the reverse ; and we 
must be careful to watch the influence of the mercury on the gums, 
as the fetor of the disease is likely to disguise the odour of the mineral, 
and so, excessive, if not dangerous, salivation be induced. 

As to common antiphlogistic measures, local or general, little reli- 
ance is to be placed upon them, even in the acute or inflammatory 
form, though a few leeches to the throat may be occasionally of ser- 
vice : bloodletting is not to be relied on, and often proves injurious ; 
and such measures are quite inadmissible in the other form of the 
complaint. An emetic, in the commencement, may be of use : and 
purgatives, according to circumstances; but we must early look 
to supporting the strength by nourishing diet ; and the administration 
of tonics and stimulants, as quinine and ammonia. Particular atten- 
tion should be paid to ventilation. Changing the child to an airy and 
healthful situation is always serviceable, if not. essential to recovery ; 
and we must insist on the necessity for at once removing healthy 
children from any place in which the disease has appeared. 



Gangrene — Gangrena Oris. — A particular form of gangrene of 
the mouth, without preceding inflammation or ulceration, occasion- 
ally attacks infants, especially such as are very feeble at birth, or 



ISO 



DISEASES OF THE DIGESTIVE ORGANS. 



broken down by disease ; but this disorder may occur in older 
children, from two to six years of age, when debilitated by ill health, 
or of a feeble, strumous habit of body ; particularly such as have 
suffered from worms, or live in low, damp situations in towns — the 
disease often appearing, indeed, to appertain exclusively to one 

locality. 

An oedematous circumscribed swelling appears on the cheek, with 
a central point more or less hard, over which occurs a dark red 
spot. This spot may appear on the inside or outside of the cheek ; and 
the skin over the oedematous part is characterized by an oily appear- 
ance ; while the whole cheek presents a deadly pale hue, and the 
oedema generally extends to the eyelids of that side, so as to close 
them. An eschar forms from within outwards on the central point ; 
and the soft parts mortify, often extensively, down to the bone, so 
that the parietes of the cheeks and gums are destroyed, — falling off 
in shreds, mixed with a dark sanguineous fluid, and accompanied by 
a very fetid odour. The pallid hue of the affected cheek is, in this 
disease, very characteristic ; but such an appearance is more or less 
to be observed in most cases of inflammation or ulceration of the 
mouth of children, as a natural consequence of the increased action 
going on within, and is the more remarkable when contrasted with a 
heightened colour in the opposite side — a circumstance judiciously 
pointed out, by Mr. W. C. Byrne, (see Medical Press, vol. iv., p. 182,) 
as an indication of morbid action, which should lead us to examine 
the mouth, although no complaint may have been made of that part, 
nor other indication of the disease given. 

No disease can be more frightful or formidable than sloughing of 
the mouth in children. Recovery seems impossible, when once the 
disease has set severely in, the child sinking beneath the constitutional 
disturbance, independently of the local ravages of the disorder, which, 
however, are often such as to render recovery not to be desired, 
so frightful is the deformity necessarily entailed : yet occasionally 
recovery will take place, after the disease has committed much local 
ravage ; and even the appetite and rest may continue unimpaired up 
to an advanced period of the complaint. The fever, which may have 
been at first high, then sinks into low t}rphus; the bowels become great- 
ly deranged, and diarrhoea often attends at the close.* The early 
application of the muriatic acid, as already advised (p. 179), is the 
only efficient application in these forms of gangrene, unless we 
would try the butter (chloride) of antimony, as a powerful caustic, 
capable of destroying the unsound surface, without causing any 
inflammation in the surrounding parts. This, however, is by no 
means a merely local disorder ; and attention to the state of the bowels, 
the administration of bark, wine, and the mineral acids, with a 
nutritious diet, the occasional use of an opiate, and above all, change 

* Mr. Dease the elder describes a disease of this description, under the name of 
"gangrenous erosion of the cheek;" and by Mr. Burns, a similar disorder is de- 
scribed as Noma. The subject has been largely treated of by Continental writers. 
See Isnard's Dissertation sur une Affection Gangreneuse particuliere aux Enfans; 
and Baron's Memoire sur une Affection dela Bouche. — Bullet, de la Faculte, 1816. 



AFFECTIONS OF THE MOUTH, ETC. igl 

to a new and healthy locality, afford us our principal chance of 
success in attempting to arrest the progress of the complaint, which 
is one, happily, of rare occurrence. 

td malignant pustule, commencing on the inside of the cheek, 
and extending outwards to the skin, may succeed to small-pox, 
measles, or scarlatina ; and take a course as severe or destructive as 
that of the disease just described, from which, in truth, it does not 
essentially differ. Huxham notices, in his Reports for July, 1745, 
mortification of the mouth and fauces as occurring after measles, the 
disease during which we have oftenest seen this affection, although 
by no means confined thereto ; neither does it take place only in 
female children, as some have asserted. Dr. M. Hall (see Edinb. 
Med. and Surg. Journal, vol. xv.) states, that all the cases he observed 
occurred after antecedent disorders of the digestive organs, typhus 
fever, or some inflammatory disease. 

The malignant pustule of the cheek is obviously analogous to the 
pemphigus infantilis, or gangrenosus, if not identical therewith, as 
we have been accustomed to regard it ; differing only as to the part 
of the body in which it occurs ; for the two diseases (or rather two 
forms of the same disease), have been seen occurring at the same 
time and place among sick children. A striking example of this 
fact is given by Mr. Ryland, in his interesting Report on the diseases 
of children, in the seventh vol. of the Transact, of the Prov. Med. 
and Surg. Association ; for at the time that these affections of the 
mouth prevailed among several children at the Birmingham Asylum, 
labouring under measles, other children were attacked, while suffer- 
ing from the same complaint, with the affection of the pudenda, 
described by Mr. Kinder Wood, and recognised as a pemphigus in 
this work (see Constitutional Diseases). The affections of the mouth 
occurring, however, during these febrile complaints, or when recover- 
ing therefrom, are not necessarily of so severe a character, but oftener 
present the milder and more ordinary form of ulceration of the gums, 
known by the name of canker, and in which, although sloughing 
may occur, the ulcerative process predominates. 



Cancrum Oris. — It is not uncommon to see ulceration of the 
mouth occurring in children, and at times ending in mortification, 
which has been described by authors under this appellation, and is 
noticed by Dr. Cuming, (formerly assistant physician to the Dublin 
Institution for the Diseases of Children,) in an excellent paper on this 
subject, printed in the fourth volume of the Dublin Hospital Reports. 
He confines this appellation to a form of ulceration, generally com- 
mencing in the gums, and thence extending to the lips and cheeks. 
It may be acute or chronic ; and is more liable to be attended by 
sloughing, the more acute it is ; but the ulcerative process still pre- 
dominates, and by it, principally, is the destruction effected. This 
variety of the disease, according to Dr. Cuming, does not attack in- 
fants at the breast, nor under a year and a half old ; but is met with 
in children between twenty months and seven years of age ; and 
16 



1S o DISEASES OF THE DIGESTIVE ORGANS. 

occasionally assumes a very destructive character, running into a 
deep, foul, dark, and sloughing ulcer. We, not unfrequently, see 
ulcerations of the gums and mouth in children, particularly about the 
periods of first and second dentitiou, which present some of these 
characters, but are, generally speaking, neither severe in form, nor 
dangerous in degree. The gums are more or less spongy, and the 
ulcers deep and foul, but small in size. At the period of second 
dentition, in particular, such may be seen ; the worst cases appearing 
to arise from the irritation caused by several teeth being shed at the 
same time; or rotten stumps being allowed to remain in the gums, 
without being extracted. When such is the cause, the removal of 
this source of irritation must be our first step towards effecting a 
cure. 

The several remedies already recommended in ulcerations of the 
mouth are applicable in this disease ; the nitric acid lotion or the 
muriatic acid being, in bad cases, our chief resource. Black wash 
has, in milder cases, proved very beneficial ; or the tincture of iodine 
as recommended by Mr. John Davies. 

The danger of ulceration of the mouth in children is enhanced, or 
a new danger created, when mercury is intemperately given during 
the progress of these febrile complaints, or indiscreetly exhibited 
during recovery therefrom ; or, indeed, while the system in children 
labours under any disease of low vital manifestation. Sudden, severe, 
and destructive salivation is thus not unfrequently set up, by which 
the gums are quickly destroyed, so that the alveoli have been laid 
completely bare, and the ulceration extending to the cheek and taking 
on a phagedenic character, has produced all the most frightful ravages 
already described; with the additional suffering and danger of a 
state of mercurial erythism. This affection has been noticed by Dr. 
Stokes in his lectures ; and some cases will be found recorded in the 
1st vol. of the Lancet for the years 1838-39. We have seen the 
disease brought on oftener by the incautious administration of a dose 
of calomel given as a purgative to a feeble child, just recovering from 
scarlatina or measles, than as the result of mercurials administered 
during these diseases — but thus also may the attack be induced. It 
is a frightful and fatal affection, to be treated on principles similar to 
those already laid down, with the addition of such measures as are 
usually adopted to mitigate or counteract excessive salivation. It is 
more than this, however, being a form of destructive ulceration that 
seems to be peculiar to the child, and deserving of a distinct notice, un- 
der the name of cancrum oris mercuriale. 

[gangrene op the mouth. 

The frequent occurrence of gangrene of the mouth in children, and 
the great importance of detecting the true character of the disease in 
its earliest stages, from its being then very generally within the 
control of appropriate and well directed remedial measures, but, 
if it be neglected or mismanaged until the greater portion of the 
soft parts about the mouth have been destroyed, its fatal termination 



AFFECTIONS OF THE MOUTH, ETC. 



183 



can seldom be prevented, or if haply life, under such circumstances, 
is preserved, a serious and permanent deformity being entailed upon 
the patient, are reasons which seem to demand a more full and ex- 
tended notice of the etiology and treatment of this affection than is 
given in the text. 

The invasion of gangrene of the mouth is often slow, it being pre- 
ceded, for days or even weeks, by a state of indisposition more or less 
decided in different cases. The child is commonly observed to labour 
under symptoms of general debility, listlessness, and indisposition to 
engage in play, or even to move about — it cries frequently, is discon- 
tented, and desires to sleep, without the ability. The countenance is 
pale and dejected, and a puckering of the cheeks about the corners of 
the mouth is, not unfrequently, remarked. The bowels are either cos- 
tive, the discharges when procured being dark and fetid ; or frequent, 
small, and unhealthy stools occur, often attended with severe griping 
pains. The child becomes emaciated, and is subject to nocturnal 
sweats. The appetite for food is lost, or irregular and capricious — 
the thirst is in general increased. This state of things having con- 
tinued from eight days to two weeks, the patient begins to complain 
of sharp pains in his mouth and gums ; fetor of the breath soon 
manifests itself, accompanied with an increased secretion of saliva, — 
a sense of itching or pricking, and heat, is experienced in the gums, 
which assume a dark red hue, become tumid, and bleed upon the 
slightest touch. The salivation augments rapidly, accompanied, in 
general, with a slight discharge of blood ; the salivary glands at the 
same time become enlarged and painful. The appearance of the 
disease at this stage has a very marked similarity with the affection 
of the mouth resulting from a mercurial impression, and we have 
known even experienced physicians to mistake it for the latter. 

When the disease of the gums is allowed to progress, the perios- 
teum separates from the roots of the teeth ; these become loose, and 
are covered with a coating of mucus of a dirty-white colour. Fre- 
quently they fall out of their sockets. It is at this period that fever 
generally occurs, at first, in the latter part of the day, and accom- 
panied with an increase of the night sweats ; diarrhoea, also, is not 
unfrequent. The disease may continue in this state for many weeks, 
or even months, as Drs. Wepfer* and Coatest have observed. More 
commonly, however, in a few days the gums become covered with 
vesicles of an ash colour, which rapidly enlarge, unite together, and 
rupturing, show the gums beneath to be black and gangrenous ; or 
gangrenous ulcerations occur, with slightly inflamed, elevated, uneven 
and irregularly circumscribed edges, their surface being of a gray, 
or rather greenish colour, and rough. When the black or gangre- 
nous portions of the gums separate, an ulcer, similar in form to the 
slough, is left, which assumes immediately a gangrenous appearance. 
The gangrene extends itself very rapidly, laying bare the alveola 
and a large portion of the inferior maxillary bone. The teeth fall 

* Observations Med. Prac. 1727, p. 947. 
f N. A. Med. and Surg. Journ., vol. 2. 



184 DISEASES OF THE DIGESTIVE ORGANS. 

out, and portions of dead bone are thrown off, should the little 
sufferer not sink under the disease at an earlier period. From the 
gums, the gangrene is propagated to the lips, cheeks, and other soft 
parts of the face, which become more and more swollen as the dis- 
ease progresses. Upon the mucous membrane of the mouth one or 
more grayish spots make their appearance, and in a few hours 
change into ulcers that present the same characters as those already 
described, and occasion invariably a great loss of substance. In 
from three to seven days the mortification will frequently extend 
itself to the whole of the soft parts surrounding the mouth, which 
exhale a cadaverous odour, and discharge a putrid sanies. The 
fever, which now augments in intensity, assumes a hectic character, 
and the child dies, generally about the eighth, or at the latest on the 
fourteenth day after the commencement of gangrene. 

In another form of gangrene of the mouth, the general system is 
not affected to so great an extent as in that just described, and the 
disease attracts but little attention, until the gangrene has commenced. 
Until then, the patients preserve much of their accustomed gaiety — 
play about, and, in fact, present no symptoms from which the occur- 
rence of so serious a malady could be anticipated. The patient 
becomes, in general, all at once fretful and peevish, and affected with 
slight accessions of fever, especially towards evening. These symp- 
toms are, in general, accompanied with restlessness, nausea, vomit- 
ing, diarrhoea or constipation. The mortification, in these cases, 
generally makes its appearance on the centre of one of the cheeks, 
or at the commissure of the lips, from whence it extends, in many 
instances, when the disease has arrived at its height, to the gums 
and maxillary bones. Usually, the cheek becomes swollen, hard, 
red, or perfectly white, and shining ; an increased secretion of saliva 
takes place, and there is exhaled from the mouth a peculiar and 
highly offensive odour. On examining the inner surface of the 
affected cheek, one or more small, ill-looking vesicles are perceived, 
which, after a few days, rupture and form a malignant ulcer of a 
dirty-gray colour, which augments rapidly in size, having a rounded 
form, with red, distinctly circumscribed, edges. This ulceration is 
not always immediately detected, and occasionally it is entirely 
overlooked, in consequence of the attention of those about the child 
being fixed entirely upon the external swelling of the cheek, as well 
as from the little patient being unable, in consequence of the swell- 
ing, to open his mouth to any extent. When the ulceration upon 
the internal surface of the cheek has continued some time, and become 
deeper and more extended, there occurs on the external surface, 
where the tumefaction is the greatest, a livid spot, surrounded by a 
red areola, — this soon becomes of a darker colour, and increasing in 
size, extends finally, in the course of from four to eight days, to the 
lips, nose, and surrounding parts. Portions of it are soft, and of a 
gray or greenish hue, and present all the characters of humid gan- 
grene, while other parts are completely mumified, hard, and of a 
deep black. On examining the mouth, the gums are found to be 
destroyed only in that part opposite to where the gangrene in the 



AFFECTIONS OF THE MOUTH, ETC. X85 

cheek had commenced — while the rest of the gums are to all 
appearance entirely unaffected. In the progress of the disease, the 
general functions of the system become more and more impaired, — 
the appetite is destroyed, — the thirst augments, — the symptoms 
of gastric disorder augment in intensity, — the diarrhoea becomes 
more copious, and the abdomen is distended with gas, — the debility 
of the patient rapidly increases, while the intellectual functions 
remain unimpaired. The fever finally assumes a low nervous cha- 
racter — the little sufferer falls into a soporose condition; symptoms 
of universal colliquation now manifest themselves, and death occurs. 

The examination of the bodies of those who have fallen victims 
to gangrene of the mouth are too few in number, and have been 
performed with too little accuracy, to furnish any facts calculated to 
throw light upon the nature of the disease. So far as our own 
observations extend, which, however, have been very limited, the 
stomach, intestines, and liver have presented indications of preceding 
inflammation of a more or less chronic character. 

It is stated by Dr. Anderson, formerly physician to the Childrens ? 
Asylum of this city, that in the examination of the bodies of those 
who had died of the disease in that institution, under his care, he 
detected a very considerable enlargement and induration of the 
mesenteric glands, a scrofulous condition of the glands of the neck, 
and in every instance a diseased condition of the lungs, — these 
organs being, in general, thickly studded with tubercles in various 
stages of inflammation and softening. 

Gangrene of the mouth usually occurs in children of a delicate 
constitution, of a scrofulous diathesis, with soft and flaccid muscles, 
pale skin, and in whom, very generally, the functions of assimila- 
tion and nutrition have become deranged, from a series of morbific 
causes to which the little patients have been for a long time exposed. 

The disease seldom occurs excepting among the children of the 
poor. The causes which are enumerated as those favouring its pro- 
duction are, insufficient or unwholesome food — the influence of a 
damp or impure atmosphere, or that rendered impure by a number 
of persons being crowded together in small, low, and ill-ventilated 
apartments; personal and domestic filth; want of sufficient exer- 
cise, and various chronic affections of the stomach and bowels. As 
the children of those who live on the borders of the sea are exposed, 
at one and the same time, to many of these causes, gangrene of the 
mouth is, in consequence, an affection extremely prevalent in Holland, 
Sweden, and many parts of England. According to Thomassen* and 
Thysen,t two Dutch writers, who have published interesting accounts 
of the disease, it occurs frequently as an epidemic in the Netherlands, 
after various eruptive and gastric diseases. It likewise often pre- 
vails epidemically in hospitals destined for the reception of children; 
in the Childrens' Asylum of Philadelphia, Dr. Coates states, that at 

* Geneeskondig Magazyn, vol. 3. 

j- Amsterdam, 1824. Rust and Caspar's Reperlorium, 1825. 
16* 



lg6 DISEASES OF THE DIGESTIVE ORGANS. 

one period, among the two hundred and forty inmates, seventy were 
affected with the disease. 

In the cases which have fallen under our notice, the gangrene of 
the mouth occurred invariably in individuals who had laboured for 
some time under symptoms referable to gastro-intestinal irritation. 
Richter* enumerates, as a fruitful cause of the disease, the previous 
existence of febrile affections, especially the exanthematic : an imper- 
fect crisis, or the sudden suppression (metastasis) of acute affections 
of the skin would appear, he remarks, to favour, in an especial 
manner, the development of gangrene of the mouth. 

The disease is almost exclusively confined to the period of child- 
hood. It occurs most commonly at some period between the first 
and tenth year, but especially between the second and fourth. 
Seldom, if ever, has it been observed in infants during the period of 
suckling. 

As to the real nature of the gangrene of the mouth of children, 
there still exists much obscurity. Klaatsch,t G. C. Hesse,J and 
Weigand§ maintain, that what has been so generally viewed as a 
gangrenous affection of the gums, and soft parts surrounding the 
mouth, is to be attributed to a decomposition of their tissues, perfectly 
analogous to what takes place in the softening of the stomach, uterus, 
and other organs, entirely independent of gangrene. This hypothesis 
is strongly opposed by Richter, who maintains, that the disease is a 
simple mortification, resulting from preceding inflammation of the 
parts in which it occurs, of an asthenic character. 

Dr. Seibert,|| who has traced the diagnosis of the disease with 
much skill, believes that a scorbutic tendency in the system is essen- 
tial to its production, but that the scorbutic character is only fully 
developed in consequence of the reaction which takes place in the 
system when the disease of the mouth has reached its acme, and 
hence it is very frequently taken for the effect of the former rather 
than its cause. 

We believe the disease to be, in every instance, the result of inflam- 
mation, occurring in subjects in whom assimilation and nutrition 
have been impaired by preceding long-continued gastro-intestinal 
irritation. But why the inflammation should attack particularly the 
mouth, and so generally terminate in gangrene or gangrenous ulcer- 
ation, are questions to which we are able to offer no satisfactory 
answer. Dr. HeuterIF conceives it to be probable, that the affection 
of the mouth is caused by the predisposition to disease in the gums 
of children, owing to the irritation of teething. This irritation, he 
remarks, which occurs with the first dentition, and is again induced 
by the appearance of the second set of teeth, may predispose to gan- 

* Der Wasserkrebs, Berlin, 1828. 

f Hufeland's Journal, 1823. 

J Pierer's Medizinischen Annalen, 1826. 

§ De Canoro, quem aqnaticum vocant, 1827. 

|| Hufeland's Journal, 1811. 

f Der Wasserkrebs, Berlin, 1829. 



AFFECTIONS OF THE MOUTH, ETC. 187 

grene of the mouth in patients exposed to the influence of particular 
morbific causes. That the irritation of teething may be the exciting 
cause of the disease in many cases is very probable, but that it is 
not so in all is shown by the observations of Dr. Coates, who found 
few if any cases to occur during either the first or second dentition. 

In regard to the prognosis of gangrene of the mouth, we may 
remark, that it is in all cases to be viewed as a disease of a very 
formidable character. According to Richter, it produces, in at least 
the majority of instances, the death of the patient : — by the fifth, or at 
furthest, the fourteenth day from its invasion, the patient ordinarily 
sinking under the state of exhaustion which then suddenly occurs. 
Saviard* states, that he lost every patient affected with the disease 
under seven years of age. Muys,t Lund,J Seibert, Klaatsch, and 
Reimann§ assert, that they very generally succeeded in curing the 
gangrene of the mouth when it commenced by a tumour in the cheek, 
or by a livid spot. Richter considers, that when gangrene of the 
mouth occurs subsequently to affections of the stomach, it is less 
malignant than when it succeeds to fever or affections of the skin, in 
individuals of a scorbutic habit. 

Judging from our own experience, we should say that whenever 
the physician is enabled to attack the disease by appropriate reme- 
dies at the period of its development, in the greater number of cases 
he will be enabled to arrest its further progress, and save the life of 
the patient. It is important, therefore, that he should be aware of 
the circumstances under which gangrene of the mouth ordinarily 
occurs — and of the phenomena of the disease in its earliest stages. 
In very few instances have we failed to effect a perfect cure when 
we have been called in sufficiently early. This is also the experi-* 
ence of Dr. Coates, and other practitioners of this city, who have seen 
much of the disease. 

The disease is, however, peculiarly unmanageable and destructive 
to life when it occurs as an epidemic, especially in hospitals destined 
to the reception of children, and the asylums of orphans. In children, 
likewise, who are constantly exposed to the influence of causes 
injurious to health, gangrene of the mouth is seldom recovered from. 
Whenever, also, the gangrene is of any extent, the recovery of the 
patient is rarely to be anticipated, — the restoration of the parts 
destroyed always demanding a degree of vital energy which seldom 
exists in the delicate and enfeebled system of the little sufferer. 

In the majority of cases, the treatment of gangrene of the mouth 
consists simply in the application of remedies adapted to arrest the 
further progress of the local disease. When, however, we are called 
in previous to the appearance of the gangrene, in many cases, 
much may be done to prevent its occurrence — by adapting our 
remedial measures to remove the existing predisposition. Whenever 

* Observations Chirurgicales, 1702. 

f Praxis Chirurgica, 1685. 

X Transactions of the Royal Swedish Academy, 1765. 

§ De Nomate, 1824. 



1SS DISEASES OF THE DIGESTIVE ORGANS. 

it can be accomplished, the patient should be subjected to the influ- 
ence of a dry and pure atmosphere ; the strictest cleanliness of both 
person and clothing should be enjoined, together with a diet suffi- 
ciently nourishing, unirritating, and easy of digestion, and adapted, 
in respect to the substances of which it is composed, to the actual 
condition, in each case, of the digestive organs. Whatever disease 
the patient may be labouring under, which, judging from our own 
experience, will, in the majority of instances, be found to be some 
form of gastro-intestinal irritation — should be treated by its appro- 
priate remedies, recollecting, however, that alterative doses of calo- 
mel, even when indicated by the symptoms present, are to be em- 
ployed with the utmost caution, in every instance in which we have 
reason to apprehend the occurrence of gangrene of the mouth — when 
cautiously prescribed, and their effects carefully watched, they will, 
nevertheless, often be productive of beneficial results. In a few in- 
stances, we have found the administration of the sulphate of quinia, 
and a lotion to the gums of a strong decoction of black oak bark, re- 
peated frequently in the course of the day, to be beneficial in pre- 
venting gangrene of the mouth, where we had every reason to anti- 
cipate its speedy occurrence. 

The remedies that have been employed externally, with the view 
of arresting the local disease, are very numerous. All of them are 
reported to have succeeded in the hands of some physicians, while 
in those of others they have entirely failed. 

The lotion which we have found by far the most successful, is a 
solution of sulphate of copper, as employed by Dr. Coates in the 
Childrens' Asylum. His formula is as follows : — 

R. Sulph. Cupri, 3ij. 

Pulv. Cinchonse, ^ss. 
Aquae, ^iv. M. 

This is to be applied twice a day very carefully, to the full extent 
of the ulcerations and excoriations. The addition of the cinchona is 
only useful by retaining the sulphate of copper longer in contact with 
the edges of the gums. A solution of the sulphate of zinc, 5j- to 
an ounce of water, by itself, or combined with tincture of myrrh, 
Dr. Coates found to be also useful in some cases. 

Lunar caustic, which is spoken of in the highest terms by Guer- 
sent* in that form of the disease in which the gangrenous destruction 
commences on the internal surface of the cheek, was the only local re- 
medy employed in the cases of gangrene of the mouth which occurred 
in the Childrens' Asylum in this city, from June 1st, 1S27, to January 
1st, 1830 — the greater proportion of which cases terminated favour- 
ably. As soon as the disease of the mouth was detected, the caustic, 
either in pencil or in solution, was applied freely to the parts affected, t 
The lunar caustic was tried, also, by Dr. Coates, but without any 
decided advantage ; we have, ourselves, never employed this remedy, 

* Journal Hebdomadaire, No. 91. 

t See North Amer. Med. and Surg. Journ., vol. 2, p. 3S. 



AFFECTIONS OF THE MOUTH, ETC. 189 

having always been perfectly satisfied with the effects of the sulphate 
of copper : — the success, however, which has attended its use in the 
institution referred to, recommends it strongly to the attention of 
the physician. 

Richter considers that, as a local application, a decided preference 
should be given to the sulphuric, muriatic, and acetic acids, and the 
muriate of soda in solution. Heuter likewise states, that these are 
the local remedies most to be depended on, especially the acetic and 
muriatic acids used in conjunction, — while Guersent considers one 
of the very best local applications in the gangrenous affection of the 
cheek to be a mixture of muriatic acid and honey. When the acids 
are employed, Richter remarks, that to obtain from them beneficial 
effects, their application should be repeated every half hour, or at 
furthest, every hour. They should be applied either by a pencil, or 
by covering the affected parts with lint moistened with them, and 
continued until the gangrene ceases to spread, and granulations are 
formed. 

The administration of internal remedies would appear to interfere 
but little with the progress of the disease, or aid in arresting its 
fatal termination. In general, a light and nutritious diet — and the 
administration of the sulphate of quinia in solution, will, however, 
be found beneficial as adjuvants to the local treatment. 

The early extraction of the loosened teeth is an important measure, 
which should never be neglected. — C] 



Cynanche Parotidoea — Mumps. — Children are liable to an inflam- 
matory affection of the parotid gland, which often extends to the sub- 
maxillary, and is of a specific character,not tending to suppuration, but 
running a regular course of about four days' duration, when it usually 
ends by resolution. This disease, which is known by the familiar 
appellation of the mumps, is not exclusively confined to childhood, 
though most frequently seen at that period ; at times it spreads as 
an epidemic, particularly among the children of the poor ; and it is 
decidedly contagious. 

Symptoms. — A small external tumour, occupying the site of the 
parotid gland, appears generally at both sides of the neck together ; 
but is occasionally to be seen at one side only. The tumour which 
was at first remarkable and circumscribed, soon becomes extensive 
and diffused, often involving the maxillary glands in the inflammation, 
and continuing to increase until the fourth day. The tumour is hard 
and somewhat painful ; but little fever or constitutional disturbance 
in general attends, unless when the swelling becomes of considerable 
magnitude, as it occasionally does, so as to impede deglutition or respi- 
ration, and cause congestion of the brain. At times, but very rarely, 
the tumour will thus proceed to suppuration, and may cause imme- 
diate death, by discharging its contents into the larynx, if it bursts 
internally ; or lead to great deformity, when it opens outside. 

Most usually, however, the tumour begins to decline on the fourth 
day, altogether disappearing in a few days more, and with it any 



190 



DISEASES OF THE DIGESTIVE ORGANS. 



febrile symptoms that may have attended. The swelling, when going 
off, is liable to be transferred to other glands, the testicle in the male 
or mammary gland in the female, where it runs a course similar to 
that which it does in its first situation, or occasionally alternating 
between these glands, and those of the neck ; and is at times so severe 
as to cause suppuration in the testis or mamma. In general, how- 
ever, this transference of the disease is to be regarded rather as a 
favourable occurrence, the chief danger in mumps arising from the 
sudden suppression of the disease in the neck. When the swelling 
rapidly and prematurely disappears, the febrile symptoms all become 
aggravated ; and in particular, the head appears to be engaged, or 
the respiration becomes laborious, and death may follow. The sud- 
den disappearance of the morbid action from the testicle, after it has 
been established there, may also be followed by similar results. 

Mumps are not otherwise attended by danger, running their course 
in general safely, though occasionally proving troublesome from a 
chronic enlargement of the gland, remaining behind. Like other 
epidemics, a bad form of the complaint may at times prevail, espe- 
cially among the children of the poor. 

Treatment, -—Little is required in general to be done in the treat- 
ment of such a mild complaint running a specific course. When the 
febrile symptoms seem to demand interference, an emetic in the first 
instance, and some mild aperients after will be all that is required. 
In the severer cases a few leeches may be necessary to relieve the 
head, or reduce the swelling of the neck, and when the swelling is 
suddenly suppressed, stimulating liniments or a blister should be 
applied to the part where it had been. 

III. AFFECTIONS OF THE STOMACH AND BOWELS. 

The stomach and bowels are peculiarly liable to be disordered in 
the child; and these disorders may arise from mere functional derange- 
ment, as in some forms of diarrhoea, cholera, &c, or from inflamma- 
tory action, leading to organic change of structure. The functional 
derangements are most commonly induced in consequence of the 
administration of improper food ; or they may be purely sympto- 
matic, arising from sympathy with some other organ, which is in a 
state of disease. However originating, these derangements of the 
digestive organs soon tend to the production of diseased action in the 
parts affected — irritation frequently giving rise to inflammation and 
its consequences. This, however, is not necessarily the case ; and 
mere functional derangement may be so severe, or protracted, as to 
destroy life, and yet no trace of organic change be found after death; 
at least no signs of inflammatory action. To distinguish such cases 
from those which are truly inflammatory, is often a difficult, but 
always an important task. We shall endeavour to draw the line of 
distinction, being careful to set down the symptoms which indicate 
inflammatory action, and those which may exist independently of it; 
while we candidly point out those cases respecting which doubts 
must unavoidably exist. It is only by attention to the whole group 



INFLAMMATION OF THE STOMACH AND BOWELS. i 91 

of symptoms, not to any particular one, that the true distinction is to 
be attained ; and we must keep in mind that symptoms of inflamma- 
tion are liable to arise during the progress of a complaint not neces- 
sarily or originally inflammatory, as occurs in infantile cholera, pro- 
tracted diarrhoea, or remittent fever; while, on the contrary, a state 
of irritability dependent upon debility will, at times, follow true in- 
flammation as enteritis ; but which would be only aggravated by a 
perseverance in antiphlogistic measures. 

Inflammatory affections of the stomach and bowels are of frequent 
occurrence in the child ; and may arise directly from impressions of 
cold, or the effects of damp, particularly when associated with a pecu- 
liar influence exercised by the season, as we see in the frequent 
bowel complaints of children observed during autumn ; or inflamma- 
tion may be the result of a severe or continued irritation of the mu- 
cous membrane, induced by improper food ; or symptomatic of some 
existing disorder. The stomach alone may be inflamed ; but much 
more frequently the inflammation extends farther, involving the 
mucous membrane of the small intestines to a greater or less extent, 
and constituting a case of gastro-enteritis. The lower portion of the 
ileum, in particular, is a frequent seat of inflammation ; or the large 
intestines may be affected, and give rise to dysentery. 

The inflammatory action, going on in the mucous membrane, soon 
tends to its disorganisation ; ramollissement is induced, or ulceration 
set up ; but death may ensue before either of these states occur, the 
mucous membrane being found merely reddened, or injected. In 
ramollissement, the membrane becomes friable, easily peeling off" in 
soft reddish masses, when the disorganisation is caused by inflam- 
mation; but there is another form of this affection in which the 
softened membrane is white, and does not owe its origin to inflam- 
matory action. When ulceration ensues, it is found to have its seat 
in the muciparous glands or follicles, being analogous to the aphthous 
ulceration of the mouth, with which it is often combined. Excite- 
ment of the muciparous glands, however, may give rise to severe 
or serious symptoms, without their being actually inflamed or 
ulcerated. 

An alteration of secretion, identical with that observed in the 
mouth, and called muguet, may occur in the intestinal canal, but is 
seldom seen. Gangrene has, in some instances, resulted from intense 
inflammation of the mucous membrane of the stomach ; but more 
particularly of the ileum. The intestines have been thus perforated, 
and peritonitis induced on the escape of their contents ; but this is 
more frequently caused by follicular ulceration. The peritonitis thus 
induced is the most dangerous with which we can have to contend. 
Such cases are, however, happily rare in the child, but peritonitis, 
independently of this cause, occurs in the infant as well as the adult. 

When the mucous membrane of the lower portion of the canal is 
much irritated or inflamed, pain or straining attends the passage of 
the stools, or prolapsus ani is induced ; and hemorrhage of rather a 
severe character may attend, or be induced in consequence of con- 
gestion, or inflammation of the mucous membrane. 



ig2 DISEASES OF THE DIGESTIVE ORGANS. 

The fever attending inflammatory affections of the bowels is often 
severe, and the local symptoms well marked, particularly if the child 
be grown, and the attack recent ; so that in many instances no doubt 
need be entertained as to the nature of the case. In others, however, 
where the infant is very young, the invasion of the disorder and its 
progress may be so insidious, as to tend to extensive organic altera- 
tion, before the true nature of the case is suspected. The fever 
attendant on disorders of the digestive organs in the child, usually 
assumes the remittent form ; infantile remittent fever being now well 
understood to be connected with intestinal irritation, whether caused 
by extraneous matters, as worms, or undigested food; or by a morbid 
condition of the mucous membrane itself. We must recollect both 
these sources of disorder, and learn to distinguish them, if we wish 
to understand or treat this disease aright. 

The sympathetic disturbances of the head, chest, or skin, caused 
by disease of the digestive organs, whether acute or chronic, in a 
particular manner demand attention, and shall be specially noticed. 

We now proceed to consider separately the several disorders of 
the stomach and bowels, to which the child in particular is so sub- 
ject — beginning with those which are merely functional. 

Functional Disorders of the Digestive Organs — Infantile Indi- 
gestion. — The infant, as well as the adult, is subject to a train of 
symptoms arising in consequence of disagreement of the food, which, 
being unfit for the process of digestion, deranges the functions of the 
stomach, and is inadequate to supply nourishment. This may result 
from the quality of the food being such as to be unsuited to furnish 
the necessary supply of nutriment, or being unfit to undergo the 
digestive process — the infant perishing for want of sustenance, or 
in consequence of the disorder of the stomach and bowels, induced 
by improper food. 

The first form occurs with infants at the breast, who are not pro- 
vided with wholesome milk ; the other, with children who are im- 
properly or too soon fed ; and this usually takes place at the time of 
weaning. Hence we would divide infantile indigestion into two 
varieties: the indigestion of suckling, and the indigestion of weaning. 

Indigestion during Suckling. — Infants at the breast are often 
observed to look pale, lose the firmness of their flesh, and become 
emaciated. They are peevish and fretful, and constantly cry until 
they receive the breast, for which they show great avidity, seizing 
the nipple with force, and sucking eagerly; but this seems to avail 
them little, either in appeasing their hunger, or affording them nou- 
rishment. The more they suck, the more does their food disagree 
with them, being soon rejected from the stomach, or passed by the 
bowels in a curdled state. Griping, flatulency, and acidity soon 
attend ; and a protracted diarrhoea sets in, which carries off the infant 
in a period varying from two to four weeks. 

Such a state of things is often witnessed in infants suckled by 
nurses who are out of health, whose milk is too old for the infant, 
or who do not observe the rules already laid down for the manage- 
ment of infants at the breast. It is at foundling hospitals, or among 



AFFECTIONS OF THE STOMACH AND BOWELS. I93 

the nursed children of the poor, that we have extensive opportunities 
for observing such cases, many dying annually from this cause during 
the first months of infantile life. In fact, these children die of starva- 
tion. The milk they get is unable to sustain them — and tormented 
by hunger, they suck in vain to supply the deficiency by the quantity 
taken, until the overloaded stomach and bowels become irritated, or 
at length inflamed. Many, however, die merely of inanition, no 
trace of inflammatory action being visible after death ; but the intes- 
tines being found, like the rest of the integument, blanched and atten- 
uated ; the mucous membrane being soft and friable, in the state of 
white ramollissement already alluded to. 

Diagnosis and Prognosis. — This disorder is distinguished by the 
absence of inflammatory symptoms during life, or the traces of them 
after death ; and by originating in the want of nutritious properties 
in the food, not in its irritating qualities. 

Our prognosis may be favourable, if the true nature of the case be 
early detected, and the cause removed by procuring a good and healthy 
nurse ; or substituting the best mode of artificial feeding, as already 
specified. On the contrary, little hope of success can attend the 
method too often adopted, in which the symptoms are attempted to 
be met by alternate laxatives and astringents, while the cause remains 
undetected, or unremoved. 

Treatment. — If much purging be present when we first see the 
infant, this must be checked ; and a mixture of soda with opium will 
answer best. Derangement of the biliary secretion may be met by 
small doses of mercury with chalk, sparingly employed ; but if the 
child be much reduced, some tonic, as small doses of the quinine 
mixture, or a little weak chicken broth, will be required ; great cau- 
tion, however, is necessary in administering any stimulating food, 
however nutritious, as irritation thus caused would interfere with the 
process of digestion, and give rise to the train of symptoms so com- 
monly seen at the period of weaning, and which constitutes our 
second variety of infantile indigestion. 

Indigestion during Weaning. — Any sudden change of diet, even 
in the adult, is liable to be attended with derangement of the diges- 
tive organs, especially if the food given be indigestible or irritating. 
Much more is it likely to occur in the infant, whose intestinal mucous 
membrane is so sensitive and vascular. This risk all children have 
to pass through at the period of weaning, or when artificial food 
I comes to be substituted for the breast milk. 

The irritability often attendant upon teething may predispose to 
! such disagreement, if the change of food be made at this time ; but 
I there is no necessary connection between dentition and the derange- 
' ment of bowels so often attendant upon weaning, as this occurs 
( equally when artificial food is injudiciously given before as after the 
I teeth have appeared ; and is the more likely to be induced, the earlier 
j and more suddenly the infant is weaned. There seems more reason 
in the connection established between the rapid development of the 
i glandular system going on at this period, and the susceptibility of the 
j bowels, as the muciparous glands of the intestines partake of this 
17 



1 94 DISEASES OF THE DIGESTIVE ORGANS. 

general activity, and are found about this time undergoing rapid en- 
largement, and in a highly sensitive state. Hence these glands are 
peculiarly liable to become irritated; and from their irritation arise 
some important peculiarities observed in the bowel complaints of chil- 
dren. 

This derangement, attendant upon weaning, has been long the 
subject of popular observation, and known under the name of Wean- 
ing Brash : — the Atrophia Mlactatorum of Cheyne, who thus trans- 
lates the popular name, in his essay on this disease, published in 
1802.* But the history of the symptoms and appearances detailed 
after death in the majority of the cases observed by Dr. Cheyne, 
shows the disease described by him to have been of an inflammatory 
character, or to have arrived at an inflammatory stage, thus differing 
from the form of complaint, we have at present under consideration, 
and hence requiring a different line of treatment. 

The relation between the supervention of weaning brash and the 
autumnal season is so remarkable, that Dr. Cheyne doubts the exist- 
ence of the disease at any other period of the year ; and suggests that 
the weaning of delicate children should, if possible, be put off until 
this season has passed. The advice is good, in consequence of the 
greater liability to bowel complaints during the autumnal months ; 
but such will occur, as the result of improper food, at all seasons, as 
we have witnessed. 

When food, in too great quantity, or of improper quality, is given 
to a child, the stomach becomes oppressed ; and more or less of sick- 
ness or fever ensues, until the offending substance is rejected from 
the stomach, or, being carried into the bowels, is passed from thence. 
Thus vomiting or purging commonly result, in the first instance ; 
and it is well they should, being the efforts made by nature to get 
rid of the source of injury. Flatulency with pain or spasm, often 
attend in addition. Thus, much sympathetic irritation is induced ; 
and this may amount to such a degree as to cause convulsions, which 
not unfrequently result from an indigestible meal given to a child. 

Did the distress thus induced disappear with its cause, all would 
be well after the child had been vomited, or purged ; but the irrita- 
tion of the stomach and bowels, once set up, may continue ; and 
often involves other organs, particularly the liver, whose functions 
are usually more or less deranged. Thus the matters ejected from 
the stomach are frequently yellow or green, being tinged with bile ; 
and the stools are very yellow, or oftener of a deep grass-green co- 
lour ; so much so, that this form of purging has got the common 
appellation of " the green scour." On the other hand, the biliary 
secretion is at times suppressed ; the stools being light or clay- 
coloured, thin and watery, or thick, like half-boiled flummery. When 
the true source of the malady is overlooked, and the improper diet 
persevered in, under the idea that the derangement of the stomach 
and bowels arises from teething or some peculiarity in the constitu- 
tion of the child (as is commonly thought), a confirmed state of indi- 

* See Cheyne's Second Essay on the Diseases of Children. 



AFFECTIONS OF THE STOMACH AND BOWELS. 195 

gestion is established ; and the child rapidly emaciates, the skin grows 
harsh and dry, the belly becomes tumid, and constant diarrhoea or 
vomiting is established. 

The commencement of the disease is often deferred for some time 
after weaning, not appearing until a month or six weeks have elapsed, 
when the continuance of the unwholesome diet at length produces 
the derangement of bowels, which, in other instances, immediately 
follows its use. 

Symptoms. — A purging of green matter is generally the first 
symptom ; but after some time, a retching or vomiting is added ; the 
matter rejected being often tinged with bile. The diarrhoea some- 
times ceases when the latter becomes established ; or it only occa- 
ally occurs. Short periods of troublesome constipation are not 
unfrequently interposed. The child is peevish, and restless, often 
cries, and has a settled discontent of countenance, indicative of pain. 
There is much disinclination for food ; but it shows a desire for cold 
drinks. Little fever, however, in general attends. There is some 
evening exacerbation ; but the pulse is scarcely affected ; nor is 
there much heat of skin ; and the extremities are disposed to be cold. 
The belly, though full, is not tender, and the tongue may continue 
long clean and moist, or only a little whitened ; but aphthae, after 
a time, Usually appear. 

Diagnosis. — The great emaciation and feebleness of the infant, 
with the constant whine, and countenance expressive of pain, are 
the most prominent characters of the case. Such a disorder cannot 
long exist without organic disease being induced. Irritation leads to 
inflammation, and intestinal ulcerations ultimately ensue ; but many 
children die from the foregoing symptoms, from mere functional dis- 
order, without signs of inflammation being present during life or to 
be traced after death. In these cases the intestines are found empty, 
pale, and transparent : in some parts inflated by gas, in others much 
contracted, as if by spasm : one portion being involved in another, 
so as to form intus-susceptions, but without any inflammation or ad- 
hesion of the parts involved. The disease is often protracted to a 
month or six weeks, the finest infants being in that time reduced to 
the most wretched state of marasmus ; but when vomiting is added 
to the purging, the case may assume the character of cholera, and 
will often terminate fatally in a week or fortnight. When a child 
dies under these circumstances, the head almost always becomes 
engaged, coma or convulsions being present ; but this is only a se- 
condary affection, and not dependent on any inflammatory action, — 
a state of venous congestion, with slight effusion into the ventricles, 
being the appearances found on dissection. 

Prognosis. — When we are consulted in such cases sufficiently 
early, and are able ourselves to determine on the absence of organic 
disease, our prognosis may be favourable, as by removing the source 
of the symptoms, in the improper food administered, a great advance 
is made towards effecting a cure ; and it is surprising from what a 
state of exhaustion an ill-fed infant may be recovered. We must 
not, however, be deceived by a cessation of purging which occasion- 



19 6 DISEASES OF THE DIGESTIVE ORGANS. 

ally occurs a few days before death, but without materially amend- 
ing the child's condition, or retarding the fatal result. 

Treatment. — The substitution of a healthy nurse's milk (when 
the child is not too old), or asses' milk, with weak, broth, free from 
fat, thin arrow-root, and barley-water, (with gum or isinglass dis- 
solved in it,) for drink, instead of the food with which the child has 
been fed, are the principal changes requisite in the diet. Milk, in 
general, disagrees, and when given, should be previously boiled, and 
diluted with one or two parts of water. Boiled bread and milk, or 
even rice milk, though often recommended, we have frequently found 
to disagree. When the stomach is irritable, and much thirst present, 
a little cold water is the best and most grateful drink. In protracted 
cases, a good drink may be made by scraping some flour, which has 
been boiled in a napkin, and allowed to become dry, into equal parts 
of milk and water, and then boiling and sweetening the mixture. 
In general, little sugar should be used, and that of the best quality. 

Medicines. — Our object, in the first instance, should be to check 
the vomiting and purging as speedily as possible, and allay the irri- 
tability of the mucous membrane. For this purpose, opium is a 
chief resource ; and when used with the cautions already specified, 
we need never hesitate as to the utility of its employment. Hufe- 
land, in particular, commends opium in diarrhoea, consequent on 
weaning, or induced by unwholesome and ill-regulated diet — the 
kind of case now under consideration. The safest and most imme- 
diate way of checking the purging, when severe, will be by admi- 
nistering an anodyne injection, consisting of one or two ounces of 
mucilage of starch, with from two to four drops of laudanum, and 
then employing the following astringent mixture : — 

No. 39. 

R. Aquae Cinnamomi, ^k 
Misturae Cretse, gss. 
Tinctnrse Kino, 5u» 

Opii, gtts. viij. 

Syrupi Aurantii, ^U* 
Sumat 5i- — 5iJ- nor ^ quaque 2da. 

This medicine should be persevered in until sleep is induced, or 
the purging decidedly checked ; it will then be sufficient to give it 
after each liquid stool. 

If the stomach be very irritable, six grains of bi-carbonate of soda 
may be substituted for the chalk mixture in the foregoing formula, 
or the mistura anti-emetica (p. 96) employed. 

The warm bath should be ordered every night, or night and morn- 
ing, if the child's strength permit. Under all circumstances, fomen- 
tations to the abdomen, or the application of hot flannel, and friction 
with the warm hand, are of great service. Opiate liniments may, 
in protracted cases, be used with the best effect. 

Having thus allayed the more urgent symptoms, and allowed the 
child opportunity for recovering some strength, we have time to look 



AFFECTIONS OF THE STOMACH AND BOWELS. 197 

about, and regulate our line of proceeding according to the circum- 
stances of the case. 

The course just specified is that which we commonly pursue, and 
by which we have seen numbers of children speedily restored from 
great extremity, and after other means had failed. The purgative 
plan of treatment for such cases we never adopt, and are only sur- 
prised how any one who has witnessed its destructive effects can for 
a moment support it. Emetics we are equally cautious in employ- 
ing. When a case has recently occurred, and can be distinctly traced 
to a meal of indigestible food, an emetic of ipecacuanha is doubtless 
a good measure to free the stomach, and lessen the risk of farther 
mischief. In the same way, a mild dose of rhubarb and magnesia,. 
or a little castor oil, guarded by a drop or two of laudanum, is equally 
serviceable in freeing the bowels of indigestible contents which may 
still lodge there, though diarrhoea has set in; but these are particular 
and obvious cases, about which no mistake can well be made. 
When the diarrhoea is established, we seldom use laxatives ; and 
even in the occasional constipation, or rather cessation of purging, 
which at times occurs, we equally avoid their employment, — having 
often seen a diarrhoea brought back by a misplaced anxiety on this 
score, which could not again be allayed. The addition of a scruple 
of magnesia, or a drachm of tincture of rhubarb, to the astringent 
mixture, will, in such cases, obviate or remove the tendency to cos- 
tiveness. The use of mercurials, whether given as purgatives, alter- 
atives, or specifics, (as some seem to employ them in the bowel 
complaints of infants,) we consider a plan of treatment requiring 
equal caution, though we would by no means altogether forbid it. 
When the biliary secretion is much deranged, and the stools very 
foul, an occasional small dose of the hydrargyrum cum creta, or of 
calomel, is undoubtedly of service, by improving the biliary secretion, 
and thus tending to allay the irritation of the bowels ; but we always 
guard the mercurial with a grain or two of Dover's powder, or from 
two to five of the compound powder of chalk with opium. If given 
alone we never employ the mercurial more frequently than every 
second night, and that only occasionally.. Guarded by the opiates, 
as we have advised, it may, however, be used night and morning, 
or even three times a day, for some days in continuance ; and under 
this plan of treatment, the stools soon lose their unnatural character, 
becoming consistent and less frequent, the irritability of the bowels 
quickly subsiding. The Dover's powder, or powder of chalk with 
opium, will, by themselves, however, often produce the same results. 
When we do employ mercury, our usual practice is to prescribe a 
grain of hydrargyrum cum creta, with one or two of Dover's powder, 
every night, or night and morning, and to employ the astringent or 
sedative mixture at the same time. The practice of persevering in 
doses of calomel, or hydrargyrum cum creta, so often pursued, as if 
this were a cure for irritable bowels in the child, we cannot but look 
upon as a most pernicious error, having repeatedly witnessed its in- 
jurious effects. The recommendation of the efficacy of this plan by 
17* 



19S DISEASES OF THE DIGESTIVE ORGANS. 

Dr. Cheyne, in his Essay, already alluded to, (which has doubtless 
led so much to the indiscriminate employment of mercurials in the 
bowel complaints of children,) arose from the circumstance of the 
cases described by him being really of an inflammatory character, or 
having passed into that state, and so requiring the administration of 
mercury for their cure ; as will be specified when treating of the in- 
flammatory affections of the abdomen. 

When much debility is present, some stimulant is required, and 
this will be best effected by adding two or three drops of the aro- 
matic, spirit of ammonia to each dose of the astringent mixture already 
advised ; or double that quantity of the nitrous spirit of ssther, or 
Hoffman's anodyne liquor, when spasms or hiccup attend. 

Before having recourse to stimulants, however, we must examine 
whether the symptoms present may not have originated in an in- 
flammatory affection of the mucous membrane, and truly indicate a 
case of gastro-enteritis. Upon this distinction will turn our line of 
practice, as stimulants must be interdicted if inflammation be present ; 
and this may exist in conjunction with much apparent debility. As 
injurious, however, is the error of those who, taking every case of 
vomiting and purging in the child for one of gastro-enteritis, indis- 
criminately apply leeches, and have recourse to debilitating measures 
— - an error that is irremediable in the young child under such cir- 
cumstances. The employment of opiates, sedatives, and even 
astringents, is common to the two classes of complaint, the inflam- 
matory or functional ; and the external use of warm fomentations, 
stimulating liniments, or blisters, may also be looked on as applicable 
to both : but before we decide on applying leeches, or administering 
stimulants, we must see and determine whether the disease be in- 
flammatory or not. 

Cholera Infantum. — A disease of a very formidable character, 
and well-deserving this appellation, is often to be met with in the 
autumnal months. It begins to appear at the latter end of summer, 
and seems to be nearly allied to the disorder of which we have last 
spoken. The greater number of cases occur in infants at the breast, 
more particularly those winch are teething, or have been recently 
weaned : but that this disease does not necessarily arise from teeth- 
ing or weaning, though either may predispose to it, is sufficiently 
proved by its constant occurrence at the autumnal season (and that 
season only), when its attacks are not confined to infants that are 
teething, or have been weaned. Many cases are presented at the 
same time, the disease appearing as an epidemic, like other bowel 
complaints prevailing at this season. 

Symptoms. — Its invasion is sudden and violent, and its course 
often rapid, soon terminating fatally, if not promptly arrested ; but 
its progress may be protracted, and last with intermissions for six or 
seven weeks. At the time when the disease prevails, an infant is 
often presented to us, lying in the nurse's arms, completely prostrate, 
and as if about to die. The countenance is pale and shrunk, and the 
features sharpened : with a dark circle often about the lips or eyes, 
which are sunk, turned up, and half closed. The infant seems coma- 



AFFECTIONS OF THE STOMACH AXD BOWELS. 199 

tose, but is easily roused to consciousness, looking eagerly around, 
and appearing quite collected, but uneasy at being disturbed, and 
crying incessantly, until it again relapses into its former state. The 
pulse is slow, feeble, and may be irregular ; but the respiration, 
though oppressed, is not unequal, and any suspicion which may have 
at first existed, as to these symptoms originating in a cerebral affec- 
tion, is removed when we find, upon inquiry, that the attack began 
with purging and vomiting ; the bowels being frequently moved, and 
nothing remaining on the stomach. The stools are at times described 
as running from the child like water ; they may be yellow or white, 
but are much more frequently green, as if loaded with some chopped 
vegetable. The surface is cool, especially the limbs, which are at 
times quite cold ; urgent thirst often attends ; the belly is full, but 
not tender, though much sensibility of skin is present ; the tongue is 
moist, and a little white, or of a bluish tint, and feels cold : the cry 
is feeble, or almost extinct. 

This is an extreme case ; and under such circumstances, it is not 
wonderful that death should speedily occur, — the infant perishing 
in twenty-four or forty-eight hours, unless prompt relief be afforded. 
In many cases, however, the disease is much milder, being gradual 
in its development, and slow in its progress. It commences usually 
by purging in these instances, the vomiting being subsequently added. 
Remissions of the disease occur ; but the child continues restless and 
feverish, with evening exacerbations, and is subject to fits of drowsi- 
ness or oppression. The purging is occasionally absent, but again 
recurs, while emaciation goes rapidly on ; and the child is at last cut 
off by an acute attack, or gradually sinks under the disease, after a 
lapse of three or four weeks. 

Pathology. — This is obviously a species of cholera, and does not 
necessarily arise from inflammatory action, though symptoms some- 
what similar may have their origin in an insidious form of intestinal 
inflammation, often ending in ulceration, as will be presently noticed. 
That cases of inflammatory affections of the bowels often occur in 
common with the cholera infantum, resembling it in symptoms, and 
appearing at the same time, is undoubtedly, the case ; and we must 
bear in mind, that the simple cholera itself, when protracted, is liable 
to become complicated with inflammatory action ; but that the dis- 
ease is not necessarily inflammatory, or even commonly so, is equally 
certain, and not less important to recollect, as it involves a line of 
treatment not usually employed, and in recommending which as well 
as in taking this view of the subject we differ from others. Cruveil- 
hier has described this complaint under the title, Maladie gastro-in- 
testinale des Enfans,avec desorganization gelatiniforme, having on 
dissection found the mucous membrane of the stomach and bowels in 
a state of ramollissement, or reduced to a disorganised pulp, but with- 
out decided traces of inflammation. In a few cases, some redness 
has been found on portions of the intestinal mucous membrane ; but 
this appearance has been only casual, and therefore not necessarily 
connected with the disease. In general the mucous membrane is 
found pale and colourless, as if macerated in water, the intestines 



OQO DISEASES OF THE DIGESTIVE ORGANS. 

appearing almost transparent. The mucous follicles are natural, 
and even the softening of the mucous membrane is not always pre- 
sent, as has been pointed out by Guersent, who here differs from 
Cruveilhier.* 

Diagnosis. — The cholera infantum is liable to be confounded with 
congestion of the brain, or effusion, and the child generally dies with 
symptoms nearly resembling those states ; but consciousness will be 
found to exist to the last in this complaint, when the child is roused, 
and the history of the case will soon remove any doubts that may 
have been felt. 

Our prognosis must be guarded in all instances, but need not be 
hopeless even in bad cases, if seen sufficiently soon ; as recovery will 
often occur, no matter how much the child may be reduced, if suffi- 
ciently prompt measures be taken to support the strength and stop 
the evacuations ; but if the disease has been protracted so as to allow 
time for organic change, and the strength be much exhausted, the 
case assumes a new and very unfavourable character. 

Treatment. — The plan of treatment to be adopted in this com- 
plaint does not differ, in principle^ from that required for the disease 
last described ; but we must be more prompt in our proceedings, and 
our remedies must be carried much farther. In severe cases a mo- 
ment is not to be lost in attempting to stop the purging and vomit- 
ing, while we at the same time support the strength, and supply stimu- 
lants if required. 

The internal administration of stimulants requires some caution. 
Guersent altogether condemns stimulants and tonics ; but our expe- 
rience is quite opposed to this, unless where distinct signs of inflam- 
mation are present. On the contrary, our practice now is, at once 
to use stimulants, in conjunction with opiates and astringents, and 
in a much bolder manner than we at first thought of employing them. 
The mixture prescribed belowt is that which we commonly admi- 
nister, the repetition of the dose being regulated by the effect. A tea- 
spoonful is ordered to be given every hour, or half hour, until the 

* We find that Dr. Droste of Osnaburg, eonfirms the opinion which we were led 
to adopt from our observations on the Cholera Infantum, that neither the symptoms 
during life, not the morbid appearances presented after death, indicate an inflamma- 
tory affection in this disease. He looks upon the state of ramollissement of the 
intestinal mucous membrane often presented after death, as caused by an affection 
of the nerves, which supply the coats of the intestines ; but this suppositious origin 
of the softening of the membrane is less satisfactory than the opinion thrown out by 
Dr. Cars well, that the action of the gastric juice after death has something at least 
to do with producing this result. — See " Zeitschrift fur die Gesammte Medicin," ifc. 
Hamburg. 1 Band. Heft A. 1836. 

t No. 40. 

&. Infusi Mentha?, 

Aqua? Cinnamomi, aa. §i. 
Tincturae Catechu, %[]. 
Spirit. Ammon. ar. gi. 
Tinct. Opii, gtts. xij. 
Syrupi Auranti, 3ij. M. 



AFFECTIONS OF THE STOMACH AND BOWELS. o l 

purging and vomiting be checked, or sleep induced. The renewal 
of the medicine is then deferred until the symptoms recur, or the 
child awakes, uneasy or in pain. A protracted sleep frequently fol- 
lows the second or third dose of the mixture, with remission of the 
symptoms for several hours. The child awakes tranquil and refreshed, 
the vomiting often not recurring, and the next evacuation from the 
bowels beginning to assume a natural appearance. In extreme 
prostration, double the quantity of ammonia may be prescribed, or 
an equal quantity of the compound spirit of sulphuric aether be added. 
Port wine may be given in the arrow-root; and brandy and water, 
or a little burnt brandy (where much irritability of stomach attends), 
will be found highly serviceable. 

The muriated tincture of iron, given in mucilage of gum, or with 
the decoction and syrup of marsh-mallows, has been administered 
in this gastro-malacia of infants, by some German practitioners, and 
its efficacy highly spoken of by Pommer, Herzt, &c, &c. We cannot 
speak from experience of the effects of this medicine, but after the 
view we have taken of the disease, are ready to expect beneficial 
results from such a remedy; especially when we call to mind the 
astringent powers of iron in its local action on the parts to which it 
is applied. 

External stimulation by warm applications, friction, liniments or 
blisters, may be needed and will always be found useful. 

When reaction is restored, or symptoms of excitement occur, stimu- 
lants must be diminished or withdrawn ; but their continued use, in 
lessened quantity, is often required, and the still longer employment 
of opium and astringents is in most cases necessary. 

These cases must be often visited, and the effects of remedies nar- 
rowly watched. We distinguish between the narcotic effect of the 
opium and the drowsiness or oppression which attends the disease, 
by observing the readiness with which the child is aroused, and its 
consciousness on being disturbed ; neither of which will be mani- 
fested while the child is under the effect of opium, the stupor being 
then continued, and the pupils usually remaining contracted, on the 
eyes being opened. 

Again we are not to be misled by the suspension of the evacua- 
tions, or suppose that the child must be better, because the purging 
and vomiting have ceased. On the contrary this is an unfavourable 
occurrence, unless there be a corresponding general improvement, 
and in particular the drowsiness and oppression disappear, without 
being succeeded by restlessness or screaming. The purging and 
vomiting not unfrequently cease spontaneously, some time before 
death ; but the state of sinking goes on, accompanied by great rest- 
lessness, or sudden accession of the symptoms affecting the head. 
The child may appear to die comatose, yet is capable of being roused 
to the last. In such cases we must rely much on counter-irritation, 
or heat and stimulants applied to the extremities and trunk. In 
particular, hot fomentations should be applied to the head ; or it 
may be enveloped in flannels, wrung out of hot water, and then 
sprinkled with turpentine, or spirits of wine. 



202 DISEASES OF THE DIGESTIVE ORGANS. 

We must be especially careful to avoid the exhibition of any pur- 
gative after recovery from infantile cholera has taken place, even 
though the bowels remain long confined : attention to this point 
cannot be too strongly urged. 

Respecting the use of mercurials we have said nothing, because 
we never employ them in the severe cases of this complaint ; and in 
its milder forms, only under particular circumstances (such as have 
been already specified at p. 197), and never unless guarded by an 
opiate. We have found it impossible to check the purging so long 
as any form of mercury was given, in cases which readily yielded to 
the treatment recommended, after the mercury had been discontinued. 

[In the description given by Drs. Evanson and Maunsell, the 
American physician would find no little difficulty in recognizing the 
peculiar phenomena by which the disease known as cholera infan- 
tum in this country, is characterized. Neither will the plan of treat- 
ment laid down by them be found to be the one best adapted for its 
cure. 

Our authors have been led into error by confounding cholera 
infantum, which, from its being an extremely rare disease in Great 
Britain, they could have had but little opportunity of studying, with 
the maladie gastro-intestinale des enfans, avec disorganization 
gelatiniforme of the French, afnd the gastro-malacia of the German 
pathologists, from which affection it differs, however, in many im- 
portant particulars. 

Cholera infantum is a disease indigenous to this country. It pre- 
vails every year, as an endemic, in all the large cities throughout the 
Middle and Southern, and most of the Western States, during the 
season of the greatest heat : making its appearance, and ceasing, 
earlier or later, according as the summer varies in the period of its 
commencement and close. Thus in Pennsylvania, Maryland, Vir- 
ginia, Kentucky, and Ohio, it commences, sometimes in the month 
of June, and continues until October, being most rife in July and 
August ; whilst in the more Southern States it appears as early as 
April and May, and often does not cease to occur until late in 
November. 

Its only subjects are infants, chiefly between four, and twenty 
months of age — very seldom attacking those younger or older — 
being most commonly confined to the period of the first dentition. 

The disease occasionally commences with a profuse diarrhoea, the 
stools being sometimes greenish, but more commonly light-coloured, 
and very thin ; the stomach, however, soon becomes extremely irri- 
table, everything taken into it being immediately discharged, often 
with great violence. In other cases almost constant vomiting and 
purging occur simultaneously ; the discharges from the bowels being, 
ordinarily, a colourless, inodorous fluid, containing minute mucous 
flocculi. 

In whatever manner the disease commences, the patient soon 
becomes affected with great langour and prostration, and is rapidly 
emaciated — being reduced in a few days to an extent, that to those 



AFFECTIONS OF THE STOMACH AND BOWELS. 2 03 

who have not witnessed the disease, would appear almost incre- 
dible. 

The pulse is usually quick, frequent, small, and often tense. The 
tongue is covered with a thin white fur. The skin is, in general, 
dry and harsh — the head and abdomen are hot, while the extremities 
retain their natural temperature, or when the attack is violent, are 
decidedly cold. There is always great thirst ; whatever fluid is 
taken, being, however, almost immediately rejected from the stomach. 
Towards evening there occurs, in most instances, a decided febrile 
exacerbation. The patient frequently suffers considerable pain, as 
indicated by fretfulness, frequent change of posture, drawing up of 
its legs, and occasional acute cries. The abdomen is often somewhat 
tumid, and painful when pressed upon. 

While, in most instances, the irritability of stomach continues, to 
a greater or less extent, throughout the attack ; it occasionally 
happens that, after a few hours, the vomiting becomes suspended, 
while the diarrhoea continues unabated ; the irritability of the intes- 
tinal canal being such often as to cause whatever food or drink is 
taken to pass off rapidly without the slightest change. 

In some cases, at a very early period, the patient becomes affected 
with delirium — tosses its head backwards and forwards, and attempts 
to bite or scratch its attendants. 

In very violent attacks, the prostration which ensues is so great as 
to destroy the patient within twenty-four hours. In general, however, 
the disease runs a much more protracted course. The emaciation 
becomes extreme — the eyes languid, hollow, and glassy — the 
countenance pale and contracted — the nose sharp, and the lips thin, 
dry, and shrivelled ; while the skin upon the forehead is smooth and 
shining as if stretched tightly over the bone. The child lies con- 
stantly in an imperfect doze, with half open eyelids, and so insen- 
sible to external impressions, that flies have been known to light 
upon the half exposed eyeballs, without the patient exhibiting the 
least consciousness of their presence. 

The skin is now cool and clammy, of a dark brownish hue, and 
often covered with petechias — the tongue of a dark colour, smooth 
and shining, or covered, as well as the whole of the inner surface of 
the mouth, with aphthae. At this stage of the disease the fauces 
become dry, causing a difficulty in deglutition, and inducing the 
patient to thrust his hand deep into the mouth, as if to remove some 
substance from the throat. The abdomen becomes tympanitic, and 
the hands and feet pallid and cedematous. The discharges from the 
bowels are now, generally, frequent and profuse — dark-coloured 
and very offensive ; in some cases, however, they are small in quan- 
tity and composed entirely of dark-coloured mucus, mixed with the 
food or drinks that have been taken. The little sufferer becomes 
weaker and weaker — rolls its head about when awake — and utters 
constant, short, plaintive, hardly audible cries. He falls, at length, 
into a state of complete coma — death being often preceded by con- 
vulsions. Not unfrequently, at a much earlier period of the attack, 
effusion takes place in the brain, and the patient dies with all the 
symptoms of acute hydrocephalus. 



204 DISEASES OF THE DIGESTIVE ORGANS. 

Ill most of the protracted cases an eruption occurs upon the breast of 
very minute watery vesicles. This Dr. Dewees considers to be in 
every instance a fatal symptom. We have in many instances, how- 
everj seen the patient recover, even where this eruption has been 
most extensive and distinct. 

The examination of the bodies of those who have fallen victims 
to cholera infantum, exhibits various lesions, chiefly of the alimen- 
tary canal. When death takes place early in the attack, the only 
morbid appearance discovered is often an unusual paleness of the 
mucous membrane of the stomach and bowels, with more or less 
congestion of the liver. Where the disease has existed for a longer 
period, increased redness at different points of the stomach and 
bowels is often present — follicular inflammation to a greater or less 
extent, occasionally advanced to ulceration, is not unfrequentiy met 
with. Occasionally, portions of the mucous membrane, either of the 
stomach or intestines, is more or less softened ; in other instances, 
increased redness of some portion of the alimentary canal exists, 
with contraction of its calibre to such an extent as scarcely to permit 
the insertion of a small-sized quill. The bowels are, in general, 
empty, or contain merely a small amount of a thick, tenacious 
mucus. The liver is more or less congested in the generality of 
cases, and sometimes very much enlarged. The gall-bladder is 
usually filled with dark-green bile ; it sometimes, however, contains 
only a pale, nearly colourless fluid. In a large number of the more 
protracted cases, serous effusion upon the surface or in the ventricles 
of the brain is present. 

Cholera infantum is evidently dependent for its production on the 
action of a heated, confined, and impure atmosphere upon the infan- 
tile system, at a period when it is already strongly predisposed to 
disease of the alimentary canal from the effects of teething. 

The influence of a high atmospheric temperature in the produc- 
tion of the disease is shown by the fact, that its prevalence is always 
in proportion to the heat of the summer — increasing, and becoming 
more fatal with the rise of the thermometer, and declining with the 
first appearance of cool weather in autumn. During its continuance, 
it is observed to vary with every permanent change of temperature — 
a few hot days in succession in the month of June are sufficient to 
produce it ; while, during the height of its prevalence, a spell of cool 
weather will diminish, if not entirely suppress it. 

A heated and confined atmosphere is alone sufficient for the pro- 
duction of the disease in those infants who have been prematurely 
deprived of their natural aliment, or whose diet is composed of irri- 
tating, indigestible, or otherwise improper articles. 

The extensive prevalence of the disease in this country is not de- 
pendent however, merely upon the heat of our summers, but upon the 
combined influence of a high atmospheric temperature, and confined 
and impure air. Hence it is almost exclusively confined to the larger 
and more crowded cities of the Middle and Southern States, and is es- 
pecially prevalent, and destructive to life, among the children of the 
poorer classes, inhabiting small, ill-ventilated houses, situated in nar- 
row confined lanes, courts, and alleys, or in situations abounding with 



AFFECTIONS OF THE STOMACH AND BOWELS. £05 

accumulations of filth. When met with in the country, which is 
rarely the case, it is almost invariably in low, damp, and otherwise 
unhealthy situations. 

Notwithstanding cholera infantum is a disease readily cured, 
whenever we are able to carry into effect the proper remedial mea- 
sures, it is still one by which a large number of children are annually 
destroyed. The chief cause of the great mortality produced by it is, 
the impossibility, in the majority of instances, of removing the 
patients from the continued influence of those causes by which the 
disease is produced and kept up. Without this removal there is but 
little hope, in any case, of effectually controlling it by medicine — 
while, kl most cases, in their commencement at least, little else is 
required to accomplish a cure. 

In very violent attacks, it occasionally happens that the patient 
sinks at once — death ensuing in a few hours. Such cases, how- 
ever, are of unfrequent occurrence ; sufficient time being in general 
afforded for the employment of means calculated to arrest the pro- 
gress of the disease. Even after it has continued for many days, and 
reduced the patient to a state in which a fatal termination seems 
to be inevitable, by appropriate remedies, a very rapid cure may 
often be effected. 

In the treatment of cholera infantum, it is all important that the 
patient be removed at once from the heated and impure atmosphere 
by which the disease has been generated. Whenever this can be 
done in the early period of the attack — the child being, at the same 
time, confined exclusively to the breast, and immersed daily in a 
bath — warm or tepid, according as the temperature of the skin is 
deficient or increased — the disease will, generally, be arrested with- 
out the administration of anything internally, excepting perhaps some 
cool, perfectly bland, and slightly mucilaginous drink. Even in 
cases in which a removal to a healthy and airy situation in the 
country is impracticable, much benefit may be derived from carrying 
the patient frequently into the open air, in a carriage or in the arms, 
or when its residence is near a large river, sailing it daily in an open 
boat. 

In every instance the child should, if possible, be confined to the 
breast of its mother or of a healthy nurse, or if entirely weaned, to a 
diet of pure milk, with the addition of biscuit, rice, arrow-root, or 
tapioca. 

The apartment occupied by the patient should be kept strictly 
clean and dry, and freely ventilated — its clothing, besides being 
perfectly clean, should neither be too warm, so as to overheat the 
body, nor so thin and flimsy as to expose it to the influence of every 
slight change in the temperature of the air. In every instance, a 
careful examination of the gums should be made, and if they are 
found to be hot, swollen, and inflamed, they should be freely lanced. 

When the disease commences with diarrhoea, the warm bath, 
repeated daily, and followed by gentle friction over the entire surface 
of the body with the hand or a soft cloth — cold mucilaginous 
18 



205 DISEASES OF THE DIGESTIVE ORGANS. 

drinks, and one of the following powders, mixed with a little water 
and loaf sugar, repeated every two or three hours, will, ordinarily, 
very quickly arrest it. 

R. Calomel, grs. ij. 
Cretse ppt. 5 SS « 
Acetat. Plumbi, grs. vj. M. f. ch. No. xij. 

When vomiting is present, and the stomach rejects immediately 
everything taken into it, it will generally be found, that minute 
doses of calomel, from one-sixth to a quarter of a grain, rubbed up 
with a little dry loaf sugar, and sprinkled upon the tongue, will be 
retained and allay speedily the irritability of the stomach. When, 
however, the vomiting persists, we have found a few drops of tur- 
pentine, or of a solution of 5i- of camphor in 3L of sulphuric ether, 
repeated at short intervals, seldom to fail in removing it. In cases 
of violent vomiting, a few leeches over the stomach will often be 
found decidedly advantageous. When everything else fails, we 
believe that we shall seldom be disappointed in allaying the gastric 
irritability by the prescription of a teaspoonful, every hour or two, of 
the following solution : 

R. Aquae Purae, !§j. 

Acetat. Plumbi, gr. r. 
Acid. Acetic, gtt. v. 
Sacch. Alb. 3hj» M. 

A blister may at the same time be applied over the stomach for 
three or four hours, and then taken off and replaced by a bread and 
milk or flaxseed poultice. 

When the patient appears to suffer much from pain — the skin 
being hot and dry — the abdomen tumid and tender to the touch — 
leeches should be applied to the epigastrium in numbers proportioned 
to the age and strength of the infant and the extent of the symptoms, 
and followed by light emollient cataplasms or warm fomentations 
over the whole abdomen. The tepid bath should be repeated night 
and morning. A teaspoonful of cold water may be allowed every 
fifteen or twenty minutes, but the ordinary drink of the patient should 
be toast, rice, or gum water. 

In those cases in which there exists much heat about the head, 
with delirium or other symptoms of cerebral irritation, leeches should 
be applied to the temples or behind the ears, with cold lotions to the 
scalp, and some stimulating embrocation to the lower extremities. 
In all instances in which there appears to exist a tendency to disease 
of the brain, blisters behind the ears, kept open by the use of some 
stimulating ointment, will be found decidedly beneficial. 

When the irritability of the stomach is removed, the remedy which 
we have found the most certainly and effectually to restrain the dis- 
ordered condition of the bowels and complete the cure, is a combi- 
nation of calomel, prepared chalk, acetate of lead, and ipecacuanha. 



AFFECTIONS OF THE STOMACH AND BOWELS. 2Q7 

R. Calomel, gr. iij. 

Cretae ppt. gr. xxxvj. 

Acetat. Plumbi, gr. xij. 

Ipecacuanhae, gr. iij. M. f. ch. No. xij. 

One of these may be given every three hours. 

Under the use of this prescription, with the daily use of the warm 
bath, exposure to a dry and cool atmosphere, and an appropriate diet, 
we have generally found the inordinate discharges from the bowels 
to be quickly suspended, and replaced by natural evacuations. 

As soon as the frequent watery discharges from the bowels are 
arrested, we are accustomed to suspend the use of the acetate of 
lead, and continue the calomel, prepared chalk, and ipecacuanha, in 
the same proportions as above, until regular and healthy stools are 
procured. 

When the cholera infantum has been allowed to run into a chronic 
form, its treatment then will differ but little from that of chronic 
diarrhoea. The most efficient remedies are, — the warm bath, fre- 
quently repeated ; a blister over the abdomen ; anodyne injec- 
tions, composed of thin starch and a few drops of laudanum; light 
astringents, as kino, decoction of dewberry root or geranium macu- 
latum, with a change of air, and a diet of boiled milk, thickened with 
rice-flour, or plain beef tea or chicken water. In many cases the 
sulphate of quinia in solution, besides exerting a beneficial influence 
upon the disordered condition of the bowels, will be found useful in 
restoring strength to the patient. 

When the discharges from the bowels are thin, small in quantity, 
dark-coloured, and highly offensive, with flatulency and a tendency 
to a tympanitic condition of the abdomen, we have derived the best 
effects from the use of turpentine, in the following formula : 

R. Mucilag. G. Arab. %lv. 
Spir. Terebinth. 3ij. 
Magnes. Calc. gr. xiij. 
Lavend. Spir. Compos. 3*j- M- 

The dose is a teaspoonful every three hours. When great irrita- 
bility of the bowels is present, we generally direct the addition to the 
above formula of 3hj- tine, kino, and the same quantity of the cam- 
phorated tincture of opium. 

When the disease has, by a judicious course of treatment, been 
entirely removed, the restoration of the patient's strength and the 
prevention of a relapse, are only to be ensured by the influence of a 
cool and pure atmosphere, a mild, unirritating diet, and the most 
scrupulous cleanliness of his person and clothing. — C.] 



Diarrhoea. — The forms of bowel complaints which we have 
hitherto been considering, appertain more particularly to the age of 
infancy, and arise chiefly from disorder of the stomach, or indigestion. 
We now come to consider diarrhoea as more properly connected with 



OQ8 DISEASES OF THE DIGESTIVE ORGANS. 

intestinal derangement, and occurring at any period of childhood — 
the disease indeed to which the child is most subject. Some object 
to treating of diarrhoea at all as a distinct affection, looking upon it 
merely as a symptom of disease. This, to a certain degree, is just ; 
but it would be carrying our regard for pathology to a very inconve- 
nient extent, did we omit to give a distinct notice of an affection of 
such common occurrence, and originating in such various sources, as 
diarrhoea — particularly when no traces of organic lesion are, in 
many instances, to be found after death ; for diarrhoea may exist long 
as a mere functional disorder, and thus destroy life. It is such forms 
of the complaint that we now propose to notice, — diarrhoea, as a 
symptom of organic disease, being to be treated of elsewhere. 

Symptoms, — The susceptibility and activity of the digestive 
organs, already noticed, predispose to render the effects of any cause 
of irritation quickly manifested in the child, by an increase in the 
abundance and frequency of evacuations from the bowels. The 
mucous and serous excretions are copiously thrown out, the biliary 
secretion soon deranged •, and, the irritation being conveyed to the 
muscular fibre, the peristaltic action is increased, and the stools are 
ejected with greater force as well as frequency. Some sickness of 
stomach usually attends, at least on a recent attack ; but the stomach 
may altogether escape being disturbed, and the appetite remain good. 
More generally, however, the appetite is precarious, or lost ; there 
is thirst usually for cold drinks ; the tongue is loaded, being white 
or yellow, with occasionally the sides or tip red, or aphthae may be 
present. Flatulency, acidity, and griping, almost always accompany 
diarrhoea in the child. Heat of skin, particularly over the abdomen, 
is present, and an evening exacerbation usually attends. 

Such is the state of things which is certain, sooner or later, to be 
observed in the child who has been overfed, or with whom the use 
of unwholesome food is continued. Impressions of cold, the retro- 
cession of eruptive complaints, or the prevalence of catarrhal fevers, 
often lead to attacks of diarrhoea in children ; but some difference is 
to be observed in the form of the bowel complaint, according as it 
arises from one or other of these causes. Diarrhoea is also more 
likely to be connected with inflammatory action, or to lead thereto, 
when originating in such sources, than when induced merely by errors 
of diet. 

Pathology. — When diarrhoea is severe, or has long continued, 
the child emaciates rapidly, the febrile symptoms become much 
aggravated, and their remittent form strikingly marked. The skin 
grows harsh, dry, and shrivelled ; the features greatly altered, so as 
to acquire a premature resemblance to old age : the belly swells, 
generally becoming hard and tender ; while symptoms, more or less 
decisive, of organic lesion, make their appearance. In many cases, 
however, diarrhoea will destroy life, without any marks of morbid 
action being to be traced, the intestines being simply found thin, 
transparent, and in many parts much contracted, while in others 
they are inflated with gas. The bowels are usually empty of feces ; 
and the mucous membrane is pale, or it may be softened. 



AFFECTIONS OF THE STOMACH AND BOWELS. 209 

The form in which diarrhoea is presented will depend on the part 
of the intestinal apparatus that most predominates in the morbid ac- 
tion. The mucous, serous, or bilious secretions may be deranged, 
and give to the attack a particular character and name ; but these 
divisions, although found in nature and useful in practice, are not to 
be too literally regarded, as the character of the complaint is very 
liable to alter, when the attack is protracted ; and, in particular, de- 
rangement of the liver seldom fails sooner or later to appear. Hence 
the necessity for a constant regard to the symptoms, and exami- 
nation of the evacuations, the appearance of which should be a 
principal guide in directing the treatment. When the powers of 
digestion are very feeble, and the mucous membrane relaxed and 
irritable, the food may be passed unchanged, almost as soon as swal- 
lowed ; but, in ordinary cases, diarrhoea consists simply of an increased 
frequency in the motions, which are feculent but loose. 

Simple Diarrhoea. — When diarrhoea arises directly from the irri- 
tation or indigestible nature of the food, the stools are in the first 
instance feculent, — sudden and copious purging coming on, attended 
with some sickness of stomach and griping, the pain usually follow- 
ing the contents of the bowels as they pass along, and this form of 
the disease may be called simple or feculent diarrhoea. The abdo- 
men in this case is usually found full, and it may be hard or irregu- 
lar in shape, but not tense nor tender. The fulness depends on the 
overloaded condition of the abdomen, which in fact gives rise to the 
diarrhoea, and will disappear therewith. Hardness or irregularity, 
when felt in the course of the colon, and communicating the impres- 
sion of lumps being present in the abdomen, may be taken as an 
indication that hardened faeces, or scybala, are retained in the bowels ; 
and the stools should be searched for such, which will soon come 
away after the administration of a suitable aperient, should they not 
spontaneously appear. 

If the cause of the attack be not continued, it may of itself cease, 
after a few loose and feculent motions ; or it may be speedily put an 
end to by one or two doses of some mild aperient. When the use 
of improper food is persevered in, however, (as too generally hap- 
pens,) or the irritation in the first instance has been severe, the loose- 
ness of the bowels is continued, and the discharges, though still 
feculent, begin to present other characters ; but diarrhoea arising 
from this source is, for the most part, feculent at its commencement. 
The stools soon begin, however, to be charged with mucus ; and 
this is one of the most frequent characters which purging assumes 
in the child — Mucous Diarrhaza, as it has been called, being com- 
mon in childhood ; in particular, at the time of teething, but not con- 
fined to that period, as Underwood asserts. 

In this form of the complaint, the stools may consist solely of mucus, 
appearing like jelly, quite transparent, or lying at the bottom of the 
vessel, like semitransparent mucilage. At first, some fecal matter 
will be present, and the stools be variously coloured ; but their tena- 
city and consistency is what gives to them their peculiar character. 
This form of diarrhoea is usually very acute ; it may succeed the 
18* 



210 DISEASES OF THE DIGESTIVE ORGANS. 

former variety, or be joined with it ; but often sets in as an epidemic, 
prevailing at the same time with other affections of the mucous 
membranes. It may be accompanied with marked febrile symptoms, 
and connected with an inflammatory state of the mucous membrane, 
or a highly irritable state of the mucous follicles. Frequently, how- 
ever, mucous diarrhoea appears independently of any inflammatory 
state, but connected with a super-abundance of vitiated mucus, with 
which the stomach as well as bowels may be loaded, as is evidenced 
by what is vomited, as well as by the stringy evacuations passed 
by stool. The presence of worms may give rise to this form of irri- 
tation of the intestinal canal ; and we should examine the stools, to 
see if any be present in such cases ; which, however, they need not 
necessarily be. 

So much irritation can hardly prevail as in either of these forms 
of diarrhoea, without deranging the functions of the liver, and caus- 
ing a suspension of the secretion of healthy bile, or, what is more 
frequent, an inordinate flow, or a vitiated secretion. The stools are 
often of a bright yellow, or a grass-green colour ; but it is hardly 
necessary to denominate the diarrhoea bilious on that account, — this 
being an accidental, though common occurrence, during the continu- 
ance of either of the forms of diarrhoea just described. The stools 
often cause much pain, heat, or scalding, as they are passed ; and 
hence the popular notion that acrid bile is the source of the malady ; 
but the derangement of the liver and the flow of bile are, in them- 
selves, but secondary occurrences, and, what is important to attend 
to, appear often to be connected with a state of high irritation, or 
even inflammation, of the mucous membrane, particularly of the 
duodenum or stomach. 

The green colour of the motions is commonly caused by acidity, 
and they smell sour when evacuated ; or the acid may be generated 
after they are passed, and the stools become green when kept. But 
yellow and frothy, or very green stools, are often found in connection 
with enteritis ; hence we should examine, in such cases, whether 
other evidences of inflammation be present ; but not attempt to judge 
by the appearance of the stools alone, or, indeed, by any single 
symptom. Derangement of the liver causes much variety in the 
appearance of the stools, which may be dark brown, or even black, 
like pitch, and very offensive ; nor is absence or deficiency of bile 
less remarkable in its effects. To this cause, principally, are to be 
attributed those pale-coloured clayey evacuations, at times seen in 
children, and generally accompanied with constitutional disturbance. 
The fault, however, does not rest solely with the liver, which is often 
only secondarily affected, the primary source of the malady being 
disorder of the duodenum. A diarrhoea of this description, the stools 
being occasionally lumpy or pasty, though generally thin, is not an 
infrequent attendant on the cutting of the double teeth, as Under- 
wood has noticed. Fever attends, appetite is lost, and the child 
rapidly emaciates ; this being always an obstinate, and often a dan- 
gerous form of diarrhoea. 

A copious discharge of thin, watery motions, often limpid or almost 



AFFECTIONS OF THE STOMACH AND BOWELS. 2 11 

colourless, and occasionally intermixed with flakes or shreds, is often 
observed in infants, and, being accompanied by pain, has been termed 
in vernacular language the Watery Gripes. This form is truly a 
serous diarrhoea, arrising from inordinate excitement of the exhalants 
of the intestines, and is nearly allied to the mucous diarrhoea, with 
which it may be mixed. It may, like it, occur in an acute form, 
or be the result of a state of atony, or debility of the exhalant vessels. 
This form of diarrhoea, in particular, is liable to be induced by sudden 
impressions of cold on the surface, if perspiration be suppressed 
thereby ; or it may be brought on by cold or acid drinks, taken while 
the body is heated. The quantity of fluid passed by stool in this 
way is at times inordinately great, so that rapid emaciation and 
sinking ensue, the effects of the disease being like those of cholera 
as already described, and to which it at first bears no small resem- 
blance. 

Occasionally we meet with diarrhoea attended by the discharge of 
very white, as well as very copious and thin stools. This variety 
seems to resemble the last ; but the peculiarity of colour appears to 
depend on more than the mere absence of bile — probably on some 
peculiar alteration in the glandular secretion from the intestines, more 
particularly, perhaps, that of the pancreatic glands, as some have con- 
jectured. This kind of purging is always to be looked on in a serious 
light. 

During the highly irritable state of the intestinal canal which gives 
rise to these frequent and copious evacuations, it is not wonderful to 
find the powers of digestion impaired, and the mucous membrane little 
able to bear the presence of matters which, at other times, could be 
endured with impunity or advantage. Accordingly, we often find, in 
these cases of diarrhoea, that the food is passed unchanged, almost as 
soon as swallowed ; or, if at all digested, it is but very imperfectly 
changed into chyle, and even part of what is formed appears to pass 
before it can be absorbed. When this state of things existed, the term 
Lientery was applied of old, as marking a particular form of diarrhoea ; 
but this circumstance does not belong peculiarly to any one form, 
but may occur in all. M. Capuron seems to think that it belongs 
especially to the variety attended with white discharges ; but it occurs 
equally when the stools are serous. In fact, lientery exists whenever 
much excitability of the mucous membrane is present, and at the 
same time food is injudiciously given, which the stomach, being 
enfeebled, is unable to digest. 

It is while labouring under these forms of diarrhoea, the stools 
being slimy or watery, but almost without colour or smell, that chil- 
dren are presented to us in such a state of languor and distress, show- 
ing that tendency to coldness of the surface and sinking, to which 
infants are so prone when ill, especially with bowel complaints ; and 
when we must without delay arrest the disorder, or the child will 
perish from inanition, dying convulsed, before organic change has 
had time to take place. 

Severe pains and spasm often attend on diarrhoea in the child. 
These may arise from the acidity and flatulency present, and amount 



212 DISEASES OF THE DIGESTIVE ORGANS. 

to such a degree as to endanger life in the young infant. Violent 
screaming and convulsions are induced, or the child sinks as if suffo- 
cated from the oppression caused by inordinate accumulations of 
flatus ; and which is sufficient of itself to cause death by asphyxia, in 
the young child. 

In cases of infantile colic, the abdomen becomes excessively, or 
often suddenly enlarged, and is tympanitic to the touch : but in general 
the gas is felt to be unequally distributed through the bowels, and 
may be heard rumbling in the large intestines, or be perceived to 
escape from the mouth or anus. Pressure or friction with the warm 
hand gives relief. It is important to distinguish between these 
cases of flatulency, and the tympanitic state of the abdomen to be 
observed in the advanced stages of intestinal inflammation ; for the 
general state of the child is not unlike in both, — as the infant may 
be found cold, languid, or fainting, with impeded respiration, (the 
face being swollen or livid, from obstruction to the circulation in the 
head,) in a severe case of colic with flatus, without any form of in- 
flammation having been present. Acidity occasionally amounts to 
such a degree as to excoriate the lips, or redden the blue colour of 
the dress worn by the infant. We have at times seen an attack of 
infantile colic become periodical, occurring at the same hour for 
several days in succession, generally at two or three o'clock in the 
morning, at which time the child would awake, screaming, the abdo- 
men being distended with flatus : in a few cases, this occurred at four 
o'clock in the afternoon. We have not met with this kind of case, 
however, sufficiently often to look upon it in any light but that of a 
casual occurrence ; but Dr. Dewees speaks of a distinctly periodical 
colic which attacks infants, coming on, in general, from four to six 
o'clock in the afternoon, and lasting three months ; so that it has got, 
in America, the name of " the three months' belly-ache. " 

When much irritation attends any form of purging, the peristaltic 
action of the intestines is increased, so that the stools which in the 
natural state are rather squeezed out from the anus, than actually 
passed, are now ejected with force, or even with violence, asifsquirted 
from the bowels. Blood not unfrequently follows in these severe 
cases, and passes alone, or more commonly mixed with the stools. 
Needing, or tenesmus, frequently attends, — the stools being small, 
scanty, and with difficulty expelled. 

Prolapsus ani, or coming down of the intestine will occasionally 
result from irritation of the bowels ; and this is not an uncommon 
affection with children who have suffered much from bowel com- 
plaints. Indeed children are commonly the subjects of this complaint, 
being more disposed thereto than adults, both from the nature and 
structure of the parts concerned : for, not only are the viscera of the 
abdomen more voluminous, and the mobility of the intestine greater, 
in the child, but the resistent powers are less, the intestine not being 
so much curved, the sacrum more perpendicular, and the coccyx still 
moveable thereon ; while the connections of the rectum are less ex- 
tensive than in the adult, in consequence of the imperfect develop- 
ment of the neighbouring parts. Occasionally, a large portion of 



AFFECTIONS OF THE STOMACH AND BOWELS. 2 13 

the intestinal mucous membrane is protruded, and this appears to be 
highly vascular ; being presented in the form of a small pyramidal 
tumour, red and coiled, rather than in the shape of a circular fold, or 
two lateral flaps, as is most usual in the adult. If not judiciously- 
treated, and soon returned, it may inflame, ulcerate, and even slough. 
Most of these symptoms of high irritation, however, and especially 
hemorrhage, are connected with an inflammatory state of the bowels, 
and, when present, should induce a strict examination into all the 
symptoms. 

Diarrhoea is liable not merely to be protracted, but to become 
chronic, and is often presented in an exceedingly obstinate form, — a 
state of constipation alternating with that of purging, which, how- 
ever, is soon brought back by any error in diet, or induced by the 
exhibition of a purgative. In chronic diarrhoea, the great point to 
determine is, how far the relaxed state of the bowels depends merely 
on an habitual derangement of function, or want of tone in the parts, 
or continues to be kept up by the presence of irritating matters in 
the intestines, or a state of chronic disease in the intestinal mucous 
membrane. 

Our prognosis, in diarrhoea, will depend mainly on the determina- 
tion of the question, how far the disease, whether acute or chronic, 
has had its origin in inflammation. Even in severe cases of recent 
diarrhoea, if merely sympathetic, or induced only by the use of im- 
proper food, we may hope favourably, though the child be greatly 
reduced : in chronic diarrhoea, much will depend on the history of 
the case, and the probable cause which seems to keep up the com- 
plaint. When the purging appears to depend on want of tone simply, 
or on the irritability and consequently increased action dependent 
thereon, and especially if kept up by inattention to proper regulation 
of diet, or by the injudicious employment of medicines, we may look 
to a different mode of management as promising a favourable result. 
Children who have been long subject to attacks of diarrhoea, how- 
ever, or who have suffered much from the disease in early infancy, 
rarely escape with merely functional derangement of the bowels ; 
and though we may from time to time remove such attacks, we 
cannot promise, too confidently, a perfect cure ; as it will at times 
happen that, when least expected, an attack, apparently of no un- 
usual severity, will carry off the child. 

Treatment. — Diet. — Attention to diet is a chief point in the 
treatment of diarrhoea, no matter what be its form or duration. In 
regulating the diet, we will often remove the cause of the disease, 
which is commonly induced by improper food, and which may fre- 
quently be remedied by attention to this point alone ; while no 
medicines will avail, if this be neglected. The principles on which 
to ground our regulation of diet should be to give food only in small 
quantity, of the least stimulating quality, such as is easy of digestion, 
and likely to leave but little residue behind. We have already stated 
some of the points to be attended to, with respect to diet (see page 
196), at the commencement of diarrhoea, but attention to this subject 
should never relax during the existence of the disease. In the more 



214 DISEASES OF THE DIGESTIVE ORGANS. 

acute or recent stage, gum water and barley water, slightly sweetened, 
or a mixture of both, constitute at once the best food and drink. 
Arrow-root, when made thin, and with water, may next be given, 
and is the best general diet, being a mild and nutritious food, and 
little liable to become acescent ; but, unfortunately,children in general 
dislike arrow-root, and it requires to be very carefully prepared, or 
they will not taste it. Milk, in any form, is likely to disagree in the 
first instance ; even the breast milk may require to be diluted with 
water. Bread and milk, or rice-milk, are equally objectionable ; but 
rice soon becomes a chief article of diet in diarrhoea, as it leaves 
scarcely any excrementitious matter ; but it should be thoroughly 
boiled, and only moistened with a little water or broth. Light broths 
may be then tried, of which chicken broth is to be preferred ; as also 
chicken itself, for animal food, when the child is old enough, and such 
can be borne. Chicken may be given with the rice, or some of the 
gravy of roast mutton. Vegetables are to be avoided, particularly 
potatoes, and acid or unripe fruits; for which, however, there is 
often a great desire, the appetite being frequently perverted in this 
complaint. Young meats, as veal or lamb, are indigestible, and 
therefore liable to disagree ; and fish almost always does so, in con- 
sequence of the quantity of excrementitious matter left behind : but 
rules for the dietetics of children have been already laid down, and 
these are in particular to be observed with children who are subject 
to a loose state of bowels. 

Keeping the surface warm, and the skin, if possible, in a lax state, 
is a great object in the treatment of diarrhoea, particularly when 
chronic ; hence the utility of warm clothing, warm baths, fomenta- 
tions to the abdomen, and friction. Liniments containing opium, or 
more particularly an opiate plaster, applied over the abdomen, 
will be found signally serviceable in some cases, and may save the 
necessity for the internal administration of opium ; but we must keep 
in mind that the injurious influence of this drug may be thus 
equally induced, and hence desist from its employment in liniment, 
or remove its presence as a plaster, should any symptoms of narco- 
tism ensue. A flannel swathe round the abdomen is often of signal 
service, both from the warmth it imparts, and the support it gives to 
the contained viscera. The feet, in particular, should be kept warmly 
clad. 

The influence of change of air, and of a warm and equable state 
of atmosphere in removing obstinate diarrhoea, or preventing returns 
of the complaint, is most remarkable ; and such change, when prac- 
ticable, should never be omitted. 

Medicines. — The primary question respecting the medical treat- 
ment of a case of diarrhoea is, whether we should attempt its re- 
moval by the use of an aperient, or at once try to arrest the purging. 
We have already given an opinion on this subject. When the infant 
is very young, and the evacuations profuse, we must in all cases try 
to moderate the discharge from the bowels ; and we know of no 
case in which the judicious use of opium for this purpose can be ob- 
jected to, — opium being our safest, if not principal agent in such 



AFFECTIONS OF THE STOMACH AND BOWELS. 



215 



cases, whether given alone, or as an adjunct to other medicines. We 
may use aperients, as already recommended (page 209), when diar- 
rhoea is recent, occurs directly in connexion with an overloaded state 
of the bowels, and is accompanied by feculent discharges. In full 
children that are overfed, and in whom much fever accompanies the 
attack of diarrhoea, the aperient may require to be repeated two or 
three times, or occasionally renewed. So, in any case when lumps 
of feces appear in the stools, or they are loaded with depraved 
mucus, vitiated biliary secretions, or undigested matters, an aperient 
maybe required ; but it is not to be persevered in unnecessarily, nor 
administered as if it were a cure for the disease, — being, in truth, 
valuable only as removing one of the causes of the complaint, or 
sources of irritation. In the employment of mercurials, we must be 
regulated by similar principles, employing them occasionally to cor- 
rect the vitiated condition of the secretions, and so tending to re- 
move a source of irritation, but by no means to be persevered in 
longer than such effects arise from their use. When much mucus 
loads the stools, the addition of half a grain or a grain of ipecacuanha 
to each dose of the aperient, will be found a useful adjunct. This 
subject is treated of with much judgment in the article Diarrhoea, 
Cyclopedia of Practical Medicine. 

We attempt to check diarrhoea by delaying the irritation that gives 
rise to it, or employing astringents for the purpose of stopping the 
discharges. In all cases, the first indication is to be fulfilled, if 
possible ; and this will be best effected, as far as medicine is con- 
cerned, by the use of opium and the fixed alkalies or their carbonates. 
Potash or soda are preferable in the first instance ; the carbonate of 
lime, either as compound powder of chalk, or chalk mixture, then 
becomes most available, and opium always adds to the sedative effect 
of these medicines ; but even without opium, they exercise a de- 
cidedly sedative influence. This is particularly manifested when 
there is much tenesmus or irritation of the rectum, which is often 
quickly allayed by a few grains of carbonate of soda or potash, given 
in the starch injection, with or without opium ; for we have observed 
that the irritation is much more effectually removed when the alkali 
is added, that when the opium is used alone. A small suppository, 
containing from the eighth to the fourth of a grain of opium, is often 
a convenient and effectual substitute for the anodyne injection with 
the child. The following is the form in which we prescribe soda in 
solution : — 

No. 42. 

R. Aquse Cinnam. ^i. 

Mentha?, ^ss. 

Carbonatis Sodae, gr. x. 
Syrupi Aurantii, 3>j« 
Tinct. Opii, gtts. vj. M. 

gi. — £ij. hor& quaque 2da. 

Dried carbonate of soda may be given in powder, combined with 
compound powder of ipecacuanha j or ipecacuanha itself, when 



216 



DISEASES OF THE DIGESTIVE ORGANS. 



mucus is in the stools, or the skin is dry and harsh. If, in addition, 
much heat of skin and thirst be present, particularly when the palms 
of the hands or soles of the feet are hot, the use of nitre is of great 
advantage ; but it should be guarded by opium, or well diluted in 
some mucilaginous mixture. Eight or ten grains of nitrate of potash 
may be added to the foregoing mixture, and the dose directed to be 
taken in some barley water or thin gruel : and in the same way may 
be administered the following powders, which we have found very 
serviceable in diarrhoea, under the circumstances just specified. 

No; 43. 

R. Carbonatis Sodae, sic. gr. i. 
Pulv. Ipecacuanhae, gr. \. 

Ipecac. Comp. gr. i. 

Cinnam. Comp. gr. i. 

Nitratis Potassae, gr. ij. M. 

Ft. Pulveres tales sex. Sumat hora quaque 2da vel 3tia unum. 

In the more advanced stages of diarrhoea, chalk mixture is the 
preparation of this class on which most reliance is to be placed. 
When much mucus loads the bowels, lime water possesses some 
peculiar properties in effecting its removal. 

The alkalies have the advantage, in addition, of being antacids, 
and as such are often required in the treatment of the bowel com- 
plaints of infants ; but to prevent the generation of acidity, as well 
as to remove its presence, we must endeavour to restore the tone of 
the stomach, and allay its morbid irritability, by the use of narcotics 
and bitters. 

The bitter infusions make excellent vehicles for the alkalies in 
such cases, and are not employed in the bowel complaints of children 
as frequently as they deserve, — having the power of restoring the 
functions of the stomach, while they correct the irritable state of the 
bowels. Of these bitters, the infusion of hop is particularly eligible 
for its sedative properties — that of gentian, or chamomile flowers, 
as a tonic ; and the alkaline carbonates may be exhibited in either 
of these ; but the bitter which most decidedly possesses an astringent 
power is the infusion of simarouba. This is not compatible with 
the alkaline carbonates ; but one of the most useful compounds that 
can be employed, in protracted cases of diarrhoea, is a combination 
of simarouba, nitric acid, and opium, — a prescription which common 
repute attributes to the late Dr. Baillie, of London. It may be 
ordered as follows for children : 

No. 44. 

R. Infusi Samaroubae, ?iss. 

Acidi Nitrici dil. gtts. iv. — gtts. ij. 
Syrupi Caryophyl. $iv. 
Tinct. Opii, gtts. vj. 

One or two tea-spoonfuls of this mixture to be given in some bar- 
ley water, three or four times a day. Other mineral acids have been 



AFFECTIONS OF THE STOMACH AND BOWELS. 217 

recommended as astringents, in cases of diarrhoea ; but the nitrous 
acid decidedly deserves the preference, appearing to possess some 
power of allaying the irritability of the mucous membrane. Heat of 
skin and thirst, are abated, and the appetite soon restored, by the use 
of this medicine. 

When diarrhoea has long existed, the use of turpentine is occa- 
sionally of great service, after other means have failed. In such cases, 
especially when much flatus attends, we would particularly recom- 
mend the use of the terebinthinate mixture (page 98), to which 
might be added a few drops of laudanum. 

The medicines most commonly employed to act directly as astrin- 
gents, however, and check diarrhoea, are the preparations of kino or 
catechu ; and here it may be proper to state the circumstances that 
contraindicate an attempt to stop the purging. These are, when 
diarrhoea is of long standing ; when the discharge appears beneficial 
or critical, as the looseness of bowels that often attends dentition ; or 
the copious liquid evacuations which occasionally accompany the 
resolution of intestinal inflammation. Respecting long standing 
diarrhoea, we may observe, it is not easily arrested in general ; and 
we need not fear attempting to do so, if we only watch the effects of 
remedies, and desist, should febrile symptoms, or disturbance of any 
important organ ensue — a rule to be regarded in all cases. 

The diarrhoea attendant on dentition need not be interfered with, 
unless profuse, and the infant much debilitated ; but we should recol- 
lect, that severe purging is liable to occur at this period, independently 
of any irritation in the gums, and which requires prompt treatment, 
as already pointed out. 

It is in the case where the head becomes engaged during the ex- 
istence of diarrhoea, that the greatest caution is required; and we 
must carefully examine into the symptoms, to determine whether 
they arise from sympathetic irritation, or from exhaustion in conse- 
quence of inordinate evacuation —in fact, whether the symptoms be 
hydrocephalic or hydrencep haloid. In the latter case, the purging 
is to be arrested, and stimulants given, without delay ; in the former 
case, we should hesitate about suddenly checking the discharges from 
the bowels; but we should try to allay the irritation, and moderate 
their flow, by the use of the alkaline solutions, or small doses of mer- 
cury, opium being added with much caution. In the same cautious 
manner we must proceed, where the evacuations are connected with 
an inflammatory affection of the bowels; but the particulars respect- 
ing this case belong to the next division of our subject. 

Allowing for these exceptions, we have no hesitation in recom- 
mending the use of astringents, particularly kino or catechu, in the 
bowel complaints of children. 21 From half a drachm to a drachm of 

a [We have found the acetate of lead to be one of the best and 
safest astringents in profuse diarrhoea, occurring in children ; it may 
be given in the dose of from half a grain to a grain, either alone or 
combined with minute doses of opium and ipecacuanha. In pre- 
scribing the acetate of lead, in the diseases of children especially, it 
19 



21 s DISEASES OF THE DIGESTIVE ORGANS. 

the tincture of ether, may be added to each ounce of the alkaline 
mixture recommended at page 215, and given in all cases where the 
purging is severe, even though much general excitement at the same 
time be present. This excitement depends much on the state of irri- 
tation of the mucous membrane, which also leads to those alterations 
in the secretions so usually manifested by the appearance of the stools, 
and to which the irritation has been attributed as a consequence, 
whereas it is commonly the cause. Accordingly, we constantly find 
the stools quickly becoming consistent, and assuming a natural 
character, as well as diminishing in frequency, under the use of this 
astringent compound, without the employment of a grain of mer- 
cury, though these effects are commonly considered as peculiarly 
belonging to the influence which this medicine exercises over the 
functions of the liver. In fact, we would support our view by the 
line of argument adopted by those who advocate mercury exclusively 
— they give mercury to alter the secretions, and so lessen the irrita- 
tion : we give the medicines just recommended, to lessen the irrita- 
bility of the bowels, and so alter the secretions, commencing, as we 
conceive, at the right end. 

It is a different case where the source of the symptoms has its 
origin in an inflammatory affection of the mucous membrane — there, 
other measures become necessary ; but it remains to be seen, even in 
such cases, whether astringents be necessarily excluded. We have 
the authority of M. Bally in favour of the utility of kino in relieving 
diarrhoeas, accompanied by inflammatory and febrile symptoms, — 
the class of abdominal affections which we now proceed to consider. 

Inflammatory Affections of the Digestive Organs. 

When diarrhoea has existed for some days in an infant, and febrile 
symptoms suddenly set in, we have good reason for suspecting inflam- 
mation, and should look for the symptoms that characterise enteritis. 
To determine the existence of an inflammatory affection of the sto- 
mach or bowels, however, we must take all the symptoms and the 
history of the case into account. We have seen how severe the suf- 
ferings may be in mere functional disorder of these organs in the 
infant ; and on the other hand we shall find, that intense inflamma- 
tion may exist, so as to destroy life, or lead to irremediable organic 
change, and yet be accompanied with few symptoms calculated to 
arrest attention or point out the serious nature of the malady. A 
child will perish, in such cases, with little apparent cause for the fatal 
result ; which is commonly attributed, in a vague manner, to an affec- 
tion of the head. 

Symptoms. — Inflammatory affections of the abdomen occur in 
very young infants, and are perhaps most common in those under 
six months old. In such young children, the symptoms are chiefly 
local, and often obscure ; there is little constitutional fever, and the 

is important that no substance be given at the same time that may- 
have a tendency to decompose it. — C] 



AFFECTIONS OF THE STOMACH AND BOWELS. 219 

pulse, in particular, is seldom disturbed. When, however, we find a 
child with a full tense belly, and tender to the touch, — uneasy, and 
not liking to be moved, — lying on its back or side, with the legs 
drawn up, and affected with purging and vomiting, we have little 
reason to doubt that the case is one of intestinal inflammation. This 
we can have no doubt of, if we find, in addition, the skin, particu- 
larly over the abdomen, very hot, the tongue dry and red with thirst, 
and an erythematous redness around the anus. The fever will be 
more distinctly marked the older the child is ; and the symptoms 
will vary in their character, according as the inflammation is situated 
in the stomach, or some particular tract of the intestinal canal ; and, 
again, according as the inflammation be simply one affecting the mu- 
cous membrane, or involving an affection of the mucous glands. 

The acute febrile symptoms, even when present, often soon cease, 
and give way to those of sinking, with much prostration of strength, 
the skin becoming cool or livid, and the belly losing its tenderness, 
but remaining tympanitic ; the evacuations from the bowels may 
cease, and symptoms of convulsions or cerebral congestion set in. 
When children are presented to us in this state, the previous history 
must be a chief guide in determining the true nature of the case. 

Gastritis. — Inflammation of the mucous membrane of the stomach 
may occur alone, but is usually accompanied by inflammation of the 
bowels. Gastritis may be met with in the youngest infant, and 
seems, in such instances, generally to arise in consequence of a state 
of congestion of the mucous membrane with which the child has 
been born. The symptoms which in particular characterise gastritis 
are, pain upon pressure over the stomach, which makes the child 
wince or cry, the more so, the more we press ; and vomiting imme- 
diately on taking food, or soon after, accompanied by distressing 
hiccup. This symptom, however, is not common ; and there may be 
no vomiting, nor even dryness or redness of the tongue, — nor any 
febrile symptom, if the infant be very young. In those more grown 
the nature of the case is made clearer by heat of skin, dryness and 
redness of the tongue, and perhaps quick pulse, with intense thirst, 
particularly for cold drinks ; but in severe cases, the smallest quan- 
tity of fluid may not be borne by the stomach. There is great 
restlessness, with occasional stupor. The bowels may be costive, or 
the stools natural. 

Enteritis occurs much more frequently than gastritis, and may 
exist without it ; but more commonly both are combined, constituting 
a case of gastro-enteritis. According to M. Billard, this combination 
occurs in children nearly twice as frequently as enteritis alone, and 
ten times as frequently as gastritis. In enteritis, the tenderness over 
the abdomen is situated lower down, is more diffuse, and often less 
acute than in gastritis. The skin uniformly is dry and hot, particu- 
larly over the abdomen, which soon becomes tense or tympanitic. 
In this affection the legs are drawn up, and the countenance peculiarly 
expressive of distress. Much thirst is felt, and hot drinks are occa- 
sionally preferred. The pulse is never quickened in very young 
infants, seldom so in those even after six months. Vomiting is often 



220 DISEASES OF THE DIGESTIVE ORGANS. 

present in enteritis ; but not so frequently as in gastritis, nor does it 
occur so immediately after taking food. The matter vomited is often 
yellow, and may occasionally be fecal. The state of the bowels is 
very variable. The stools may be natural, but generally are much 
depraved in appearance. Costiveness may attend, but most com- 
monly diarrhoea is present, — the evacuations being thin and frothy, 
and of a yellow, or more frequently green colour. There may be 
neither redness nor dryness of the tongue, nor disturbance of the 
stomach ; but when gastritis is conjoined, or has been superadded, 
the symptoms which characterise that affection are combined with 
those belonging to enteritis. 

Some varieties in the symptoms of enteritis are to be observed, 
according to the tract of the intestinal canal in which the inflammation 
is seated ; and this is found very frequently to be in the ileum, 
particularly in its lower portion. It is not, however, easy to deter- 
mine this point, especially in a child ; but it is important to have 
some clue to guide us in our investigations ; for these affections of 
the ileum are of common occurrence, and very insidious in their 
nature, frequently leading to a fatal result without their existence 
being suspected during life. 

Ileitis. — This affection is seldom met with before dentition has 
commenced. It is to be distinguished as much by negative as posi- 
tive signs, — the general symptoms of an abdominal affection being 
present, without those denoting inflammation of the stomach or of 
the large intestines. The child is hot, particularly over the abdomen, 
and some tenderness may be found, on pressure, between the um- 
bilicus and crest of the ileum ; but neither the heat of skin nor the 
tenderness are remarkable, and there is a tendency in the surface to 
become cool, and the extremities to grow cold. Tympanitis is 
uniformly present, and soon sets in. There is thirst, but not for cold 
drinks ; hot ones are preferred, and this is accounted a distinctive 
character of this affection. The tongue is usually white on its upper 
surface, but red at the edges and tip, and pointed. In the child, little 
febrile action is present. The pulse may be small and quick, with 
in general great prostration of strength, the features being sunk and 
contracted. Neither vomiting nor purging necessarily attend ; but 
when a child that has been feverish is affected by diarrhoea, accom- 
panied by greater debility than the diarrhoea could account for, we 
may suspect ileitis. The state of the urine serves as a diagnostic, 
being scanty, high-coloured, and often so distressing in this case, as 
to lead to the supposition that the kidneys may be affected. This 
symptom is particularly dwelt upon by Dr. Stokes, in his Lectures, as 
belonging to ileitis ; and though observations respecting the urine are 
not so easily made in the child, we have seen the value of this symp- 
tom verified. When vomiting attends, the matter rejected may be 
feculent, in consequence of the obstruction offered to the passage of 
the feces by the tumefaction of the ileo-ccecal valve, which the 
inflammation causes when seated therein. 

If the inflammation extend farther, and engage the mucous mem- 
brane of the large intestines, the case assumes a new character and 



AFFECTIONS OF THE STOMACH AND BOWELS. 221 

a new name. It now becomes one of dysentery, or of colitis, ac- 
cording to more modern nomenclature. Inflammation of the large 
intestines, however, rarely occurs alone, being in general combined 
with that of the small intestines, and entero-colitis is, according to 
M. Billard, nearly as common a disease in the child as enteritis. In 
this complaint we universally have tumefaction of the abdomen, and 
pain on pressure, with that redness around the anus which attends 
on irritation of the lower portion of the intestines, and seems caused 
by the alvine evacuations. The pulse is seldom raised, and is often 
feeble. The skin is generally hot and dry, but has a tendency to be- 
come cool or livid. This is particularly remarkable when the in- 
flammation is confined to the large intestines ; and in this case the 
tympanitic swelling of the abdomen is at first less constantly observed : 
neither does vomiting often occur, though occasionally present. 
Vomiting, however, often attends when the small intestines are in- 
volved in the inflammation; and the tongue will be red and dry, 
though no gastritis is present : but the vomiting does not occur on 
taking food, and the matter rejected is usually yellow. This is also 
the general colour of the stools, which are, however, often green, — 
diarrhoea being a frequent, though not constant, attendant on these 
cases. Much irritation is present ; the stools are passed with pain, 
or ejected with force, accompanied by straining or tenesmus ; or only 
a little mucus, tinged with blood, is evacuated. 

Hemorrhage often accompanies intestinal inflammation in the 
child, and may amount to an alarming degree ; but generally, only 
a little blood is mixed with the stools. When blood is passed, it in- 
dicates a high degree of irritation or inflammation of the mucous 
membrane, particularly of the large intestines ; but in very young 
children copious hemorrhage may occur inconsequence of congestion 
merely, independently of inflammation. 

The sympathetic relations of gastro-intestinal disease are particu- 
larly important in the child, being very liable to occur, and very 
severe when they do take place ; so as often to obscure the original 
disorder, the local symptoms of which become so much lessened on 
the occurrence of the sympathetic irritation, as to be frequently 
quite overlooked, the case being treated altogether as a cerebral or 
thoracic affection. 

Diagnosis. — The head is especially liable to become engaged in 
cases of intestinal inflammation occurring in the child, the symptoms 
of cerebral disturbance apparently possessing the severity and assum- 
ing the character of acute meningeal inflammation, into which sym- 
pathetic irritation would soon merge, if the state of the head were 
neglected, or the true nature of the case overlooked. When inflam- 
mation of the stomach or bowels in the child runs high, or is accom- 
panied by decided febrile symptoms, we soon perceive the child to 
become restless and uneasy ; it cries out, or starts in its sleep ; the 
head is hot, the eye wild, or it looks fixed and rather sunk ; there is 
intolerance of light or sound ; with tossing of the head, spasms of the 
limbs, or convulsive movements. An inexperienced or inattentive 
observer would have no doubt that the head was the seat of disease ; 
19* 



222 DISEASES OF THE DIGESTIVE ORGANS. 

but attention to this alone will not remove the symptoms, so long as 
their origin in gastric or intestinal disease is overlooked. We have 
already noticed the cerebral symptoms resembling those of effusion, 
which may accompany the state of exhaustion induced by the pre- 
sence of abdominal disease, and shall have again to recur to them, 
when speaking of the hydrencephaloid disease. The respiration is 
always more or less hurried in acute affections of the abdominal vis- 
cera in children. The breathing is rapid or oppressed ; there is pal- 
pitation, and often cough of an irritative and harassing kind ; but 
we observe that the respiration, though apparently impeded, is car- 
ried on by the thoracic, not abdominal muscles; and we find, on 
examining the chest, an absence of those signs which indicate pul- 
monary inflammation. Examination by the stethoscope should be 
duly made, and our treatment directed accordingly. 

Whatever tract of the mucous membrane be the seat of the inflam- 
mation, its form may vary ; and according to the form of the inflam- 
mation, a difference will be observed in the progress of the case, and 
the appearances found after death, when the result has been fatal. 
The simple or erythematous inflammation may end in resolution, 
when the case proceeds favourably, — the symptoms becoming 
milder, perhaps accompanied by copious discharges from the bowels ; 
or, the inflammation may become chronic, — the symptoms growing 
milder, but still persisting in a greater or less degree. When the 
case has terminated fatally, we observe on the mucous membrane 
traces of inflammatory action more or less distinct. 

Morbid Appearances. — There may be a ramiform redness of some 
portions of the membrane ; or the redness may appear to be caused 
by injection of the capillary vessels, and this is considered as indi- 
cating a severer form of inflammation ; or the redness may be seated 
in the tissue of the mucous membrane, and be disposed in patches, 
points, or red lines. These red patches are distinct, often ending 
abruptly, and when seated in the small intestines, may be perceived 
through their attenuated coats j but when situated in the stomach, 
no external mark is visible. 

The stomach is often found distended with gas, but may be con- 
tracted ; and when it is so, the creases of the mucous coat will be of 
a deeper colour than the other parts. In slight cases of inflamma- 
tion of the small intestines, the valvulae conniventes alone are dis- 
coloured. In severe forms of intestinal inflammation, disorganisation 
of the mucous tissue, or gelatiniform ramollissement may occur, — 
the membrane being reduced to a soft, discoloured mass, easily 
coming off like a red pulp, and leaving the coats of the stomach so 
fragile and thin, as readily to give way on the slightest pressure. 
Perforation of the stomach may thus occur during life ; and young 
infants sometimes perish suddenly from this cause. 

Gangrene is a rare consequence of intestinal inflammation in 
children at the breast ; but in those more grown, it is not of unfre- 
quent occurrence, if the inflammation has been severe, or stimulanis 
have been administered, in consequence of the nature of the case not 
having been understood. Gangrene may occur as the result of gas- 



AFFECTIONS OF THE STOMACH AND BOWELS. 223 

tritis : but is most frequently observed in the small intestines, near 
the termination of the ileum : complete perforation of the intestine, 
with escape of its contents, thus ensues. 

The papillae or villosities of the mucous membrane may be en- 
larged or tumefied ; and that form of inflammation which leads to 
altered secretion, and constitutes the disease which is denominated 
muguet, occasionally occurs in the mucous membrane of the intes- 
tinal canal, but very rarely, compared with the frequency of its oc- 
currence in the mouth. It may be found in the stomach ; but, in 
these cases, it generally passes down the oesophagus, which will be 
often found affected with the disease, without its having extended to 
the stomach. It may be met with in parts of the intestines, but is of 
very rare occurrence. We judge of its presence by seeing this pecu- 
liar white secretion passed by stool during the existence of enteritic 
inflammation. 

The alteration of the glandular apparatus of the bowels, analogous 
to what constitutes aphthous ulceration in the mouth, is often met 
with both in the large and small intestines, particularly the latter ; 
but is less liable to occur in the stomach. When aphthae appear in 
the mouth during the existence of enteritis, they often indicate a 
similar state of some part of the intestinal mucous membrane, gene- 
rally in the small intestines. When aphtha? appear at the verge of 
the anus, the large intestines are more likely to be their seat; but 
they may appear in the mouth, or anus, without occupying the in- 
termediate tract. 

The lining membrane of the stomach and bowels, when inflamed, 
is generally found covered by an adhesive mucus. The extension 
of the inflammation to the mucous follicles is of frequent occurrence, 
and constitutes that important variety of intestinal inflammation, 
which has got the distinguishing epithet of follicular. This affection 
of the mucous glands frequently takes place in children, and is often 
an unsuspected source of danger in infantile disease. These mucous 
glands are scattered over the membrane singly, or in patches. In the 
stomach and large intestines they are isolated ; but occur in clusters 
in the small intestines, and, when inflamed, appear slightly elevated, 
like small reddish pimples, with a spot or orifice in the centre. When 
about to ulcerate, they soften, become white, and sink in the middle, 
or suppurate, — appearing often like a brown slough or eschar, but 
without surrounding swelling. This form of disease is not common 
in the stomachs of children. Some cases, recorded by M. Billard, 
occurred in very young infants, and seem to have been attended with 
great debility, but without purging or vomiting. 

In the intestinal mucous membrane of children, however, this form 
of ulceration is often met with, and is a common termination of en- 
teritis, particularly when seated in the lower third of the ileum ; but 
it may occur in other parts of the small intestines, and also in the 
large, — ulceration of this form being the lesion on which is found to 
depend chronic diarrhoea, or dysentery, In most instances where they 
end fatally, particularly the latter disease.. These mucous follicles 
are hardly to be perceived just after birth, but increase in size as th$ 



224 DISEASES OF THE DIGESTIVE OltGANS. 

infant grows older, and seem to undergo rapid development about the 
time of dentition, as already remarked. These glands may be excited 
or irritated, particularly about this period, without being actually 
inflamed, or passing into ulceration ; and to this excitement of the 
intestinal glandular apparatus, and consequent increase of their 
secretions, is in great measure to be attributed the copious watery 
diarrhoea of infants. Under these circumstances, the highly irritated 
glands are very liable to become inflamed, and much judgment is 
required in the management of the case. Suddenly arresting the 
discharge might tend to this effect ; but the debility often induced by 
the inordinate evacuation from the bowels, imperatively demands 
attention to this point. During the progress of febrile attacks, and 
often in the course of remittent fever, the follicular glands, particu- 
larly in the ileum, are liable to become inflamed, and to pass into 
ulceration. Such morbid conditions are not unfrequently the cause 
of those protracted illnesses, in children, which go by the names of 
worm- or bilious fevers. 

Dr. Crampton gives an account in the second volume of the Dublin 
Hospital Reports, of an affection of the glands of the intestines occur- 
ring in children during the prevalence of fever, in the year ISIS. 
The ages of the children varied from three to eight years. The 
mucous membrane was found in many places highly vascular, and 
covered with granulations of a yellow colour, as if a coating of 
yellow wax adhered to them : in others, the granulations were of a 
dirty white hue ; and in several, ulcerations had taken place, and 
was disposed in patches of small ulcers, with well-defined edges. In 
cases which terminated favourably, a quantity of " yellowish, branny 
scales" was observed in the stools, floating on the liquid discharges, 
" like minute portions of wax from honey-comb." This appearance 
in the stools of children affected with dysenteric fever, Dr. Crampton 
had before observed, and often witnessed during the catarrhal fever 
which prevailed in Dublin in the year 18 IS. It does not appear 
that this morbid condition was the cause of the fever, as it existed 
independently of any febrile disorder, in some instances. When 
attended by fever, there was unusual abdominal tenderness, loaded 
tongue, intense thirst, occasionally vomiting, but more frequently 
diarrhoea, tenesmus, slimy and green stools, mixed with blood. 
" When remedies proved ineffectual, a true dysenteric state became 
established, the tubercles on the mucous membrane were converted 
into ulcers, and the patient died in a hectic, emaciated condition." 
Acute attacks of mucous or serous diarrhoea, attended with much ex- 
citement, and soon assuming an inflammatory character, are often 
met with among children during the prevalence of catarrhal fevers, 
or after attacks of measles, scarlatina, &c, &c. The disease may 
assume a dysenteric form, and appears to be contagious. When, 
during convalescence from such disorders, we find a child losing his 
appetite and flesh, while symptoms of remittent fever begin to show 
themselves, and then diarrhoea sets iu, we may suspect a morbid 
condition of the mucous membrane of the small intestines, involving 
the muciparous glands, and should be on our guard accordingly. 



AFFECTIONS OF THE STOMACH AND BOWELS. 225 

These various forms of intestinal inflammation are liable to become 
chronic. The child then emaciates rapidly ; the skin grows harsh, 
dry, or dirty looking, and the limbs are wasted ; but the abdomen 
is full, and may become hard or tense. There is thirst, with loss of 
appetite, or it is very precarious. The tongue is loaded, or dry and 
red ; the lips are parched and chapped, and often excoriated from 
being picked. The bowels are much deranged, diarrhoea being 
generally present, with foul and unnatural stools, often mixed with 
blood. The fever is decidedly remittent ; aphthae often appear in 
the mouth, or may be seen on the verge of the anus ; and if the case 
be mistaken or mismanaged, every symptom becomes aggravated, 
and the child perishes in consequence of an acute attack, or dies, 
worn out by the fever, — the head or chest becoming, in general, 
engaged towards the termination of the case. 

Prognosis. — The difference between inflammatory and functional 
disorders of the digestive organs, in the child, is not less important as 
regards practice, than as regards prognosis. No matter how severe 
are the vomiting and purging, they may often speedily be stopped, 
if the belly be not tense and tender, nor other symptoms of inflamma- 
tion present ; but when such attend, we gain little by merely check- 
ing the evacuations, which it may be even dangerous to attempt, so 
long as the inflammation is allowed to persist. In inflammatory 
affections, the danger is in the first instance from the acuteness of 
the attack, which often leads to a fatal result if not speedily arrested. 
When met by adequate means, however, the inflammation tends to 
resolution much more than to become chronic, in the child ; but we 
need not despair, should it take this turn, and even organic disease 
be set up : for ulceration of the mucous apparatus of the intestines, 
though a dangerous, is not necessarily a fatal disease, especially if 
its true nature be clearly ascertained. This is of more importance, 
as regards treatment at least, than attempting to determine the 
particular portion of the intestinal canal that maybe the seat of the 
inflammation or ulceration ; which it is especially difficult to do in 
the child. It makes little difference in our treatment, however, what 
particular part is affected, if we can only determine what the nature 
of the affection be, and thus decide whether we are to employ directly 
antiphlogistic remedies, or not. 

Treatment. — The first question is, whether leeches are to be 
employed in the treatment of the case, and how they are to be ap- 
plied. When the symptoms are decided, the case acute, and the 
child a little grown, or very robust, we should never omit the use of 
leeches in the first instance. A repetition of the leeching is preferable 
to allowing any lengthened flow of blood, which may run down the 
child, without arresting the disease : hence care is required when 
leeches are applied to the epigastrium ; and we should ourselves 
superintend the operation, so as to be able to stop the bleeding as 
soon as necessary. When the infant is very young, the use of leeches 
is a measure requiring great caution. If much tenesmus be present, 
with blood mixed in the stools, as occurs when the large intestines 
are engaged, more immediate relief will ensue from the application 
of leeches to the anus, than any other situation. 



226 DISEASES OF THE DIGESTIVE ORGANS. 

The employment of fomentations and baths constitute a principal 
part of the treatment ; and they are never to be omitted. When the 
child is feeble we may rest satisfied with the former ; but they should 
be assiduously employed. When able to bear a tepid bath, nothing 
gives more effectual relief than immersing the child in one up to the 
ribs, and keeping it in the bath for half an hour or longer. Some 
have advised cold applications to the abdomen, when the heat is very 
intense and the fever runs high ; and the effect of evaporating lotions,, 
in such cases, is spoken highly of. Stimulating liniments and blisters 
are most available after leeching and fomenting have been employed : 
when the acute symptoms have subsided, or any disposition is shown 
to relapse. Martinet extols the effects of sinapisms applied to one 
of the extremities for a quarter of an hour, or twenty minutes, several 
times in the day. We would not venture to continue the application 
of mustard or turpentine so long at a time ; but when used for a few 
minutes, until smarting is produced, much good is often done. 
Opium, added to the fomentations or liniments employed, is often of 
signal service in mitigating the severity of the symptoms. 

The internal administration of medicines requires judgment and 
caution. When the stomach is inflamed, nothing will, at times, be 
borne ; and the best plan is, to abstain from attempting to give any 
thing. This, however, cannot long be practised with the child, which 
will not survive without sustenance. Some try to meet the difficulty 
by administering nutritive enemata, — containing thin arrow-root, 
milk, weak broth, &c. ; but these are liable to irritate the bowels, 
and thus defeat their own object. The plan which we have found 
to answer best is, to withhold every thing for a couple of hours, and 
then commence with a tea-spoonful of very cold or iced water, lemon- 
ade, or gum-water slightly sweetened. The breast milk of a good 
nurse, mixed with water, will then be borne ; and we rely on the 
continued use of thin mucilage of gum, as the mildest sustenance we 
can employ. If the local applications already advised be at the same 
time adopted, the irritability of stomach soon becomes allayed ; and 
the breast milk may then be given occasionally, but in small quantity. 

When the bowels are confined, the mode of managing them is a 
matter of some difficulty. If gastritis be present, no purgative should 
be given by the mouth ; mild laxative enemata alone should be used ; 
but these must be repeated until purgation is effected, as emptying 
the bowels is important in such cases. Constipation is, at times, a 
troublesome symptom ; but when present in enteritis, we must recol- 
lect the inflammatory state in which it originates, and try to remove 
this symptom by overcoming its cause, not by the use of active pur- 
gatives. Some aperient, however, may be required ; and the com- 
pound powder of rhubarb (p. 127,) or the powder of rhubarb and 
magnesia, with a little calomel, in general answers best. A laxative 
enema may follow ; but castor oil, though commonly given in such 
cases, often causes much irritation. The best and safest general rule 
is, to depend on enemata for opening the bowels; and the injection 
of warm water simply, or very thin gruel, should be preferred when 
the frequent use of enemata is required. In some cases, where there 
was much irritation of the lower tract of the intestinal canal, with 



AFFECTIONS OF THE STOMACH AND BOWELS. 227 

needing, bloody stools, or diarrhoea, we have seen a mitigation of all 
the symptoms speedily follow the use of the warm water injection. 

The employment of mercury, in inflammation of the bowels, is as 
important in any other form of inflammation ; and next to bloodlet- 
ting holds an important rank. Calomel or hydrargyrum cum cret& 
may be given alone, or associated with opium, according as the 
bowels are confined or loose. In more grown children, the addition of 
mercurial ointment to the stimulating or narcotic liniments employed 
is of much service, and adds to the chance of affecting the month, 
which in severe cases may be desirable ; but even in the youngest 
children, mercury will exhibit its power of controlling inflammatory 
action, independently of salivation, though not in so striking a manner 
as where that can be effected. 

When diarrhoea is present, or the bowels irritable, the best form 
for giving mercury is the hydrargyrum cum creta with Dover's 
powder. Mercury is here used to subdue inflammatory action, not 
to cure diarrhoea — the mode of employing it in bowel complaints, 
which we have elsewhere condemned. 

Opium is a very important item in the treatment of inflammatory 
affections of the bowels in children, but caution is required in using 
it. Leeching, when necessary, should always precede its use ; and 
then the effect of opium is often remarkable in mitigating the severity 
of the symptoms. Opium given by the mouth helps to allay the irri- 
tability of the stomach, and administered in enema affords the speediest 
relief by lessening the irritation of the bowels; but mitigating these 
symptoms is doing little, unless at the same time the inflammatory 
action be subdued. Opium appears, in some instances, to exercise 
even this power, when used after bloodletting, or in cases where the 
child is too much reduced to admit of this measure. 

Peritoneal inflammation, arising from escape of the contents of the 
bowels through a perforation in the intestines, caused by ulceration, 
is liable to occur in the child; but even in such cases recovery has 
been effected by the administration of opium, and abstinence from 
purgatives, as suggested by Dr. Hart,* and practised, with success, 
by Drs. Graves and Stokes. 

If, when employing opium, sleep or stupor be induced, without 
the symptoms being mitigated ; or if the belly become full and tense, 
with increase of tenderness, when purging has been checked, we must 
lessen the dose of the opiate, or suspend its use. So in attempting 
to employ astringents where diarrhoea is severe, or dysenteric symp- 
toms are present, we must be careful not to have too early recourse 
to their use, and to lay them aside when any accession to the in- 
flammatory symptoms threatens. However, we have found benefit 
from their use where the irritation or exhaustion from excessive 
purging was severe, even before the febrile symptoms had dis- 
appeared. 

To support the strength during the progress of these cases, is a 
matter of importance, and should not be overlooked. When the 

* Dub. Hosp. Reports, vol. 5. 



228 



DISEASES OF THE DIGESTIVE ORGANS. 



more acute symptoms have been subdued, we must administer nutri- 
trious food in small quantities, as advised in the treatment of diarrhoea 

— beginning with a little chicken broth, which may be at first given 
cold. 

When the case has become chronic, our chief reliance must be 
placed on a careful regulation of diet, with the repeated use of coun- 
ter-irritants applied over the abdomen, and the occasional employment 
of opiates, when indicated. In protracted cases where the mucous 
membrane continues in an irritable state, accompanied by diarrhoea 
or dysenteric symptoms, the employment of the alkalies, astringents, 
or bitters, as recommended in the treatment of diarrhoea (p. 215), 
must be adopted ; or acetate of lead, nitrate of silver, per-sesqui- 
nitrate, or muriated tincture of iron, &c, be had recourse to as with 
adults in such cases. A powder consisting of equal parts of starch, 
powdered nut-galls, and Dover's powder, will be found occasionally 
to check chronic diarrhoea when every other remedy has failed of 
effect. Perseverance in the use of those remedies, when judgment is 
exercised in their selection, may effect recovery, even though there 
be evidence of intestinal ulceration. Change of air, and warmth 
applied to the surface, are essential aids in effecting recovery in all 
protracted cases. 

[We can speak from experience of the good effects, in the chronic 
diarrhoea of infants, of a combination of powdered galls, ipecacuanha 
and camphor, in proportions adapted to the age of the patient. — C] 

IV. MESENTERIC DISEASE (TABES MESENTERICA). 

Inflammation of the intestinal mucous membrane, or ulceration, 
such as we have noticed in the last section, may give rise to irritation 
in the mesenteric glands, leading to their enlargement, softening or 
suppuration, as we observe to occur in other glands from similar 
causes. Dr. Cheyne, in his Essay on the Bowel Complaints of Chil- 
dren, long since pointed out the occurrence of diseased mesenteric 
glands in consequence of intestinal irritation : and this view of the 
subject is that most popular among modern pathologists. We cannot 
deny, however, that disease of these glands may arise independently 
of disease of the mucous membrane : though such is not commonly 
the case. During the progress of tabes mesenterica, however, disease 
of the mucous membrane seldom fails to arise, especially towards the 
termination of the case, death generally ensuing in consequence : 
hence it is of great importance, both as regards the symptoms and 
treatment of the disease, to try and discriminate between the morbid 
action going on in the intestinal mucous membrane, — whether as a 
cause, complication, or consequence, — and that which strictly belongs 
to the mesenteric glands. 

Causes. — Most authors concur in regarding tabes mesenterica as 
a scrofulous disease ; and Dr. Joy (in his article, Tabes Mesenterica 

— Cyclopaedia of Practical Medicine), gives preference to the appel- 



MESENTERIC DISEASE. 229 

lation adopted by Sauvages, scrofula mesenterica. Bichat notices 
the slow progress of the complaint as characteristic of its strumous 
nature, and doubtless we shall be correct in viewing it in general as 
such ; but we must not forget its frequently and inflammatory origin 
and complications, nor allow our practice to be biassed by this view of 
the subject to the extent that the older practitioners did. 

The mesenteric glands, which are scarcely perceptible at birth, 
undergo gradual development, until about the period of dentition, 
when, in common with other parts of the glandular system, they 
begin actively to enlarge ; and accordingly we find that disease of 
the mesenteric glands makes its appearance about this period. Infants 
are seldom affected before the eighth month ; but from that time 
to the eighth or tenth year, the disease is liable to occur, — most 
frequently, perhaps, from the third to the sixth year, or about the 
seventh, as stated by Gardien. The glands of the mesentery are, 
according to Meckel and Portal, more subject than any others to 
tubercular disease ; but true tabes mesenterica is not so common a 
disorder as may be generally thought. 

The disease is met with most frequently among the children of 
the poor, especially such as are of a strumous habit — in fact, all 
circumstances tending to the production of scrofula, tend also to the 
production of mesenteric disease. Unwholesome food, in particular, 
as leading to derangement and disease of the digestive organs, has a 
direct tendency to cause irritation in the glands of the mesentery. 

Predisposition to tabes mesenterica is manifested in the general 
characters that indicate the strumous diathesis, in particular when 
the digestive organs are prone to become deranged, and the abdomen 
is unusually prominent. The latter sign is one much regarded, in 
general ; but its value is overrated, if indeed it possesses any, as a 
sign of predisposition to the disease : for until the mesenteric glands 
are much enlarged, they cannot add to the size of the abdomen, and 
this part is naturally more protuberant in the child than in the adult. 
Guersent expressly declares his dissent from the popular opinion, as 
he did not find children with a large abdomen more prone than 
others to this disorder, and on the contrary found the mesenteric 
glands diseased in those who presented no particular protuberance of 
the belly during life. This fact, all who examined into the disease 
must have observed ; and, what is more remarkable, enlarged, or 
even suppurated glands, are found occasionally in the mesentery of 
children who have died in good condition of body, and had appeared 
in good health up to the time of their death. Tubercular disease of 
the mesentery may exist alone, as well as tubercles be found in other 
situations without any being present in the abdomen ; but, most 
generally, diseased glands are at the same time found in other parts, 
or well-marked scrofulous disease of some description coexists with 
the mesenteric disorder. The most common combination seems to 
be, with tubercles in the lungs ; for even in children, Guersent 
found only a sixth of those who died in hospital, of mesenteric dis- 
ease, free from this complication. 

Morbid Appearances. — The glands of the mesentery, as we 
20 



230 



DISEASES OF THE DIGESTIVE ORGANS. 



have seen, are capable of taking on increased action, and becoming 
congested, enlarged, or inflamed, in consequence of the irritation 
caused by disease of the intestinal mucous membrane. In such cases, 
the progress of the morbid changes may be traced, by dissection, 
from an increase in the vascularity of the gland simply, to the deposi- 
tion of tubercular matter, or the formation of pus. The gland may 
be found almost natural in appearance, or only a little reddened, 
enlarged, or perhaps softer to the touch. More commonly, how- 
ever, it is partly changed into a soft, white, curd-like matter, or 
this is mixed with pus. These changes may occur without any dis- 
tinct evidence of the irritation having commenced in the mucous 
membrane ; and, what is not less important to recollect, tubercular 
matter may be deposited in the gland, or, as often happens, around 
it, without any appearance of previous inflammatory action, or even 
increased vascularity of the parts, — the glands being found pale, 
and not increased in density, even though examined in the first 
stage of their alteration. Andral is most explicit and decisive on 
this point. While they remain indolent, the tubercles are firm in 
consistence, and of a yellowish, or oftener dull white colour, and 
may not be larger than a pea; but as they increase in quantity, they 
arrive occasionally at considerable size, resembling " a heap of peeled 
chestnuts," to which they have not inaptly been compared. Tumours 
of even much larger size may be developed ; and in such cases, the 
tubercular matter not only occupies the place of the entire gland (which 
becomes absorbed), but accumulates around it ; and may even be 
found effused into the laminae of the mesentery, as stated by Portal. 
Symptoms. — The emaciation attendant upon this disease is a 
striking characteristic, and that from which its denomination, tabes, 
is derived. Tubercles in the mesentery, however, are not neces- 
sarily attended by emaciation from the first ; for they have been 
found in cases where the body was not wasted, and therefore their 
presence not suspected. Even in cases where emaciation has been 
established, and the glands in the mesentery can be felt enlarged, the 
wasting is not to be accounted for on the old supposition of actual 
obstruction to the passage of the chyle, and so wasting of the body 
from failure of nutrition ; for the glands, however enlarged, have 
not been found impervious to anatomical injections after death nor 
(as Cruikshank remarks) has "stagnation of the chyle in the first 
set of lacteals" been met with. The length of time during which 
mesenteric disease endures, makes also against this supposition ; 
when the patient dies, he perishes from the effects of some acute 
attack, or of the hectic fever which attends upon this, as well as 
other forms of tubercular disease. Indeed, emaciation does not 
become very remarkable, so long as the mesenteric tumours remain 
indolent ; but when once irritated, so as to become soft, and suppu- 
rate, hectic fever is set up, and emaciation rapidly ensues. The 
morbid condition of the digestive organs, so frequently a cause or 
consequence of mesenteric disease, doubtless contributes to interfere 
with the process of nutrition ; and probably (as suggested by Dr. 
Joy), the morbid condition of the glands themselves must interfere 
with their share in the process of perfect elaboration of the chyle. 



MESENTERIC DISEASE. 



231 



The wasting in tabes mesenterica is marked by its regularity and 
slowness — that attendant on bowel complaints, is rapid and vari- 
able, — the child recovering flesh when the disease is mitigated or 
subdued. 

It is no easy task to assign the symptoms that belong properly to 
tabes mesenterica, and separate them from those which belong to 
disorders of the mucous membrane unconnected with mesenteric 
disease, or which this complaint shares in common with other scrofu- 
lous disorders. After a careful review of the symptoms, as set down 
by systematic writers, and an attempt to verify them by observation, 
we are disposed to adopt the opinion of Guersent, and confess that 
the only unequivocal sign of tabes mesenterica is the perception of 
the enlarged mesenteric glands through the parietes of the abdomen. 
These we cannot expect to be able to feel, until they are decidedly 
developed, and the disease has made some progress, so that a degree 
of doubt must attend all such cases in their incipient stage ; yet there 
is a combination of symptoms which indicates with much probability 
the existence of the disease. These symptoms we shall enumerate, 
dwelling on those most to be relied on, and pointing out their rela- 
tion to treatment, which is not the least important consideration. 

For convenience of description, the disease has been divided into 
three periods or stages — First, the incipient stage, or that in which 
the enlargement of the glands is present, but has not yet made itself 
manifest by disturbing the general health, or deranging the digestive 
organs in any marked manner. Second, a stage of farther advance- 
ment, when the glands of the mesentery have become perceptibly 
enlarged, and the derangement of the digestive organs decidedly 
marked. This is the period at which the stools are observed to as- 
sume the white colour which they so frequently exhibit in this dis- 
ease ; and where glands in other parts (particularly the neck) are 
found enlarged. In the third stage, the mesenteric glands become 
irritated and suppurate ; inflammatory affections of the intestinal 
mucous membrane are set up ; constitutional fever is established ; 
emaciation becomes excessive ; and colliquative sweats and diarrhoea 
close the scene. Such arbitrary divisions cannot be found exactly 
accordant with nature ; but they have been adopted by authors, and 
are convenient for investigating the disease. 

Respecting the premonitory stage, we would observe, that though 
not necessarily giving rise to disorder of the digestive organs, it often 
arises in connection with such ; and whenever mismanaged or scro- 
fulous children have been subject to gastro-intestinal disease, we 
should be on the alert, and keep attention alive to the state of the 
mesenteric glands. When we find that such children recover very 
slowly ; are often subject to relapses ; that the belly remains full, and 
grows hard, while the wasting of the flesh continues (though the 
appetite be good, or even voracious during the period of convales- 
cence) ; we may suspect enlargement of the mesenteric glands, and 
should look for such. Occasionally the glands may be felt through 
the parietes of the abdomen, and this is the only satisfactory sign of 
their enlargement at this early stage. 



232 DISEASES OF THE DIGESTIVE ORGANS. 

When tabes mesenterica is established, however, and approaches 
the second stage, its characters become better marked. At this period, 
we should find the glands enlarged ; and when such are detected, 
being found hard and knotty in a distended abdomen, no doubt can 
be entertained as to the nature of the case. The examination will 
be best made when the patient is fasting. The enlarged mesenteric 
glands will be felt about the centre of the abdomen, and some slight 
pain usually attends the examination. This serves to distinguish 
them from indurated feces, which cause no pain on pressure, and are 
found lying in the course of the colon, more particularly to the left 
side. The abdominal pain that attends on mesenteric disease is not 
increased by pressure ; nor does it occur immediately after taking 
food, being neither accompanied by an inclination to evacuate the 
bowels, nor relieved when such evacuation takes place. Dr. Joy 
suggests, in addition, that it is by the concussion imparted by running, 
leaping, or by hiccup, that most distress will in this case be caused ; 
and Schmalz notices, that the pain is increased by the upright posi- 
tion, by bending of the back, or quick movement, or shaking of the 
body. The pain is protracted, lasting long, and often recurring about 
the same hour in the day; or, if absent for a few days, it is renewed 
with increased severity, as Underwood remarks. In relation to 
scrofula, it has been noticed that, in protracted cases, the pain is most 
severe in spring and autumn. Authors differ as to the character of 
the pain. Pemberton says it is lancinating and deep-seated, resem- 
bling the pain of gripes, and recurring three or four times a day. 
Guersent says it is a dull pain, and referred chiefly to the centre of 
the abdomen. Dr. Young notices its tendency to come out at the 
back or loins, in which others agree. 

The appetite is very variable, often voracious, and a desire ex- 
hibited for acid and indigestible food. Fresh meat is not relished ; 
and however nutritiously fed, the child continues to emaciate ; while 
the abdomen enlarges and becomes hard, until it presents a strange 
contrast with the shrunk limbs, and shrivelled, age-looking face, 
which are presented in the more advanced stages of the disorder. 
The derangements of the digestive organs which belong particularly 
to mesenteric tubercle, independently of inflammatory action of the 
mucous membrane, are not easily determined, if indeed such exist ; 
but when we find no aggravation of the symptoms induced by the 
use of stimulating or indigestible food, such as the child often craves 
for, we may consider that the symptoms depend more on enlargement 
of the mesenteric glands, than on disease of the digestive organs. 

The white, chalky stools, which are often observed during this 
disorder, have been looked upon as particularly attending tabes 
mesenterica, and assigned as a symptom belonging to its second stage. 
This white colour has been supposed to arise from the presence of 
the chyle, which was obstructed in its passage through the lacteal 
vessels ; while others attributed it to the admixture of calcareous 
matter in the evacuations. The error of the first supposition has 
been already exposed ; and no proof, beyond mere appearance, has 
been brought forward in favour of the other. White stools, as we have 






MESENTERIC DISEASE. 333 

before noticed, attend certain forms of irritation, or inflammation of 
the intestinal mucous membrane. According to the condition of this 
membrane, will vary the symptoms as regards the state of the stomach 
and bowels during the progress of tabes mesenterica ; the mucous 
vomitings, foul discharges, diarrhoea or constipation, acidity and 
flatulency, which have been assigned as symptoms of the disease, 
being necessarily connected only with the digestive organs. These 
are certainly very liable to be deranged, irritated, and even inflamed 
or ulcerated, during the existence of mesenteric disease ; though it has 
not been shown how tubercles in the mesentery particularly predis- 
pose to such conditions more than the presence of scrofula in general, 
such affections being most common in scrofulous children. 

Worms are not unfrequently present ; and when voided, are com- 
monly looked upon as the source of all the symptoms : they are, 
however, only an accidental combination ; though, perhaps, particu- 
larly liable to occur from the debilitated state of the digestive organs. 

According as the irritation caused by the disease of these organs, or 
by the enlargement of the mesenteric glands preponderates, will be ob- 
served a difference in the local and constitutional symptoms. In the for- 
mer case, we shall have more or less of the signs of gastro-enteritis, and 
the fever will be decidedly of the remittent type ; in the latter, the signs 
of inflammation will be absent, and the fever will assume the hectic 
character. Sufficient attention has not, perhaps, been paid to this 
point — the fever being described by some as hectic, by others as 
remittent ; or these terms indiscriminately applied : it is in fact a 
mixture of both, varying according to the circumstances just pointed 
out. 

When the disease is rapid, or the patient quickly cut off, there are 
well marked symptoms of remittent fever, and the child dies gener- 
ally of acute abdominal inflammation ; but when tabes mesenterica 
is slow and protracted, according to its usual course, the fever is a 
decided hectic, — ending in colliquative sweats and diarrhoea. During 
the existence of infantile remittent fever, we may apprehend irritation 
of the mesenteric glands, if the case be protracted, or often renewed, 
or if it occurs in children recovering from measles, &c. ; and the 
symptoms of the fever then tend to assume the characters of the 
hectic that accompanies tabes mesenterica. The tendency to chilli- 
ness in this complaint is extreme ; the least degree of cold is sensibly 
felt, and the patient hangs constantly over the fire. The skin is harsh, 
dry, and shrivelled — particularly on the extremities, which are often 
cold ; but heat of skin begins towards evening ; and as the fever 
becomes established, morning sweats set in, — which sometimes 
break out profusely on the head and chest, but may often be averted 
by keeping awake. The sensorial powers are not much disturbed ; 
but, d ulness of the faculties, fretfulness, and dislike to all exertion, 
are manifested. The child generally sleeps well, and delirium seldom 
or never occurs. The pulse is at first little disturbed, but soon grows 
permanently quick and hard. Should the enlarged glands become 
numerous, they may interfere, by their compression, with the func- 
tions of surrounding parts, as the liver, stomach, or kidneys ; or 
20* 



234 DISEASES OF THE DIGESTIVE ORGANS. 

anasarca may be induced, by obstruction to the flow of blood through 
the veins. 

In the third or last stage of the disorder, when the diseased 
glands have suppurated, much irritation or inflammation of the 
neighbouring parts usually ensues. The peritoneum may become 
inflamed, and effusion take place into the abdomen ; or, what is more 
common, inflammation and ulceration of the mucous membrane is 
established. Pus is occasionally present in the stools ; but is not 
necessarily a sign that the suppurating glands have evacuated their 
contents into the intestinal canal, as Schmalz seems to assume. Con- 
stant diarrhoea now attends, and the child perishes, after having been 
reduced to the last stage of marasmus. 

Diagnosis and Prognosis. — We have already pointed out, with 
so much exactness, the several symptoms belonging to mesenteric 
disease, in its different stages and complications, that little remains to 
be said in addition, under the head diagnosis. 

From the liability to complication with tubercle in other parts, par- 
ticularly in the lungs, we should always examine the chest in tabes 
mesenterica, to determine whether the hectic symptoms are connect- 
ed with pulmonary disease or not. Enlargement of the bronchial 
glands, is the complication next in frequency ; but is much more 
difficult to determine, and may altogether escape detection. The 
cervical or inguinal glands are often enlarged ; and when these show 
a tendency to inflame and suppurate, at the same time that the me- 
senteric disease becomes aggravated, and irritation or inflammation 
of the digestive organs is set up, we have reason to apprehend that 
softening or suppuration has begun in the enlarged glands of the 
mesentery, and our prognosis cannot but be unfavourable. This 
has been assigned as the second stage of the disease, and recovery 
from it is very rare. When arrived at its full development, or third 
period, mesenteric disease must be looked upon as hopeless. In 
the first or incipient stage, especially if the premonitory symptoms be 
attended to, we may look to treatment with hopes of success ; but to 
be successful, our remedies must be applied with much discrimination. 

Treatment. — After the view which has been taken of tabes me- 
senterica, much need not be said on the subject of treatment, — as 
this will resolve itself into the means necessary to subdue irritation 
or inflammatory action, and those calculated to support the constitu- 
tion, and cause resolution of the enlarged glands. Irritation or inflam- 
mation may exist in the mucous membrane of the stomach or bowels, 
or in the mesenteric glands themselves ; and either may give rise 
to the other. Under these circumstances, we must try and remove 
the inflammatory action by local depletion, abstinence, or careful 
regulation of diet ; and the use of sedative medicines, as already ad- 
vised in the treatment of inflammatory affections of the bowels. 

In all cases, fomentations, or the warm bath, and frictions over the 
abdomen, are to be had recourse to. When the irritation hascommenced 
in the mucous membrane, it is important to persevere in the treat- 
ment, until this affection is, if possible, completely removed ; for even 
a low degree of intestinal inflammation, if long continued, will cause 



MESENTERIC DISEASE. 335 

or keep up irritation in the mesenteric glands, in a subject predisposed 
to the disease. We must recollect, however, that mere depletion will 
not remove this condition of the glands, and if leeching be carried 
too far, the constitution may be enfeebled without the enlargement of 
the glands being resolved, — particularly if the irritation has com- 
menced in the glands themselves. Neither are we to employ this 
system too exclusively, as if there were no other sources of the malady, 
save gastro-intestinal irritation. The whole plan of treatment pro- 
posed for the cure or prevention of scrofula, often comes into play ; 
and must be acted upon, when a strumous child is the subject of the 
disease. We are not, however, at once to fly to tonics or specifics, 
as the older practitioners did, without regard to the inflammatory 
origin or complications of the disorder. Of the remedies that have 
got repute in this way, the fixed alkalies, or their carbonates, would 
soonest admit of being employed ; as when judiciously administered, 
advantage might be taken of their sedative influence on mucous 
membranes, as before explained, in addition to their known efficacy 
in aiding the absorption of enlarged glands. 

Iodine is the medicine to which we would principally look for 
effecting the resolution of the enlarged glands, when regarded as a 
tubercular deposition. Iodine appears to have effected a cure in 
some well-marked cases ; but we must keep in mind the liability of 
this medicine to irritate the stomach and bowels, and always defer 
or suspend its internal administration when such irritation is present, 
or has been induced. The compound solution of iodine (see page 
102) may be employed; but the hydriodate of potash is better, if 
the bowels are irritable. We generally prescribe it in decoction of 
sarsaparilla, — beginning with half a grain, or a grain, given in a 
dessert-spoonful of the decoction, two or three times a day. The 
addition of a little laudanum, or syrup of white poppy, to each dose, 
will lessen the liability of the medicine to disagree. Under all cir- 
cumstances the external use of iodine is admissible, and will always 
be found beneficial. W^e may prescribe the ioduretted bath ; or the 
ointment of iodine, or of hydriodate of potash, may be rubbed over 
the abdomen night and morning ; but these ointments are liable to 
irritate the skin in the child, and this irritation, though not objection- 
able in itself, will interfere with the continued use of the ointment. 
Iodine may, however, be employed in this way without any fear of 
inducing local irritation, by using an ointment of hydriodate of lead 
— ten or fifteen grains of which are to be mixed with half an ounce 
of lard. 

Mercurial ointment was formerly much used, and may still occa- 
sionally be employed with advantage ; but the use of mercury should 
never be pushed so far as to produce salivation when a decidedly 
strumous taint is manifested. The occasional use of a mercurial, 
combined with an aperient when the bowels are costive, or with an 
opiate when intestinal irritation and derangement of the secretions 
is present, may always be had recourse to with benefit. Small doses 
of calomel and antimonial powder, or nitre, when the febrile symp- 
toms run high, and there is furred tongue, thirst, and hot skin, are 



^36 DISEASES OF THE DIGESTIVE ORGANS. 

often of great service at the commencement of the disorder ; and in 
particular tend to improve the state of the appetite, and lessen its 
voraciousness. If disposed to give mercury to produce any consti- 
tutional influence, it should be to act as an alterative ; and we would 
prefer minute doses of corrosive sublimate, as recommended by Sir 
A. Cooper, and which we have often seen produce a beneficial effect 
in scrofulous disorders. 

Aperients were much relied on of old ; and in the commencement 
of the disease, when the bowels are slow, and no intestinal irritation 
present, they may be employed with advantage. A preference has 
been given to rhubarb with sal polychrest, as recommended by For- 
dyce ; or with sulphate of potash as more commonly employed. To 
keep the bowels open, and act mildly on the intestinal mucous mem- 
brane, so as to cause some evacuation therefrom, will doubtless be 
occasionally useful ; but to choose this membrane as the surface on 
which to produce a species of counter-irritation by the agency of 
purgative medicines, would be, we think, to make a very hazardous 
selection. Irritation excited on the surface of the abdomen, by means 
of stimulating liniments, is a more efficient, as well as safer plan, and 
should never be omitted. Even continued friction by the hand has 
been found serviceable in exciting the absorbents. 

The regulation of the diet is a matter of importance. Some advo- 
cate an exclusive use of vegetable and farinaceous food. When 
inflammatory or febrile symptoms are present, the diet should, 
undoubtedly, be so restricted ; but the continued use of food of this 
description, in more grown children, is objectionable, as being calcu- 
lated to debilitate the digestive organs, and generate flatulency, acidity, 
&c. Portal goes so far as to suppose that such food is even capable 
of promoting mesenteric disease, by causing a congested state of the 
glands, in consequence of the circulation in the abdomen being 
obstructed by the distension of the viscera, thus produced. Some 
animal food, as broths, &c, will be required to promote digestion, 
and support the strength ; but wine, or fermented liquors, must be 
given with great caution. In protracted cases, change of air, with 
sea-bathing during convalescence, and all means by which the 
strength can be supported, without the digestive organs being over 
stimulated, must be had recourse to. 

As to direct tonics, the moderate use of bitters and chalybeates are 
among the best ; but the preparations of iodine, or its combination 
with iron, are for obvious reasons to be preferred, when such medi- 
cines are admissible. 

In extreme cases, we can only palliate symptoms, trying to check 
diarrhoea, moderate colliquative sweats, and allay pain, principally 
by the use of opiates. 

v. WORMS. 

Children appear to be more subject to intestinal worms than 
grown people, but are by no means so subject to them as is popularly 
supposed ; nor do worms, of themselves, produce the many distress- 
ing symptoms commonly attributed to them. It has been said that 



WORMS. 23J 

worms never appear in children while at the breast ; but this obser- 
vation, although generally true,- is not absolutely so, as some few 
exceptions have been observed. 

Causes. — Weakly, ill-fed children, living in low situations, of a 
strumous habit, and such as are subject to disorders of the bowels 
are oftenest afflicted with worms. In general, all coexisting dis- 
orders are attributed to the worms, if any are present ; but they may 
exist in healthy children, and produce no distress, — their presence 
not being suspected until they are passed by stool, or discovered 
after death. Some attribute the origin of worms to inflammatory 
affections of the bowels ; but they are connected with such, only so 
far as these disorders, by inducing debility of the digestive organs, 
may predispose to the presence of the worms. Others, again, think 
that worms may cause inflammation or ulceration of the intes- 
tines, and thus, by penetrating their coats, give rise to peritoneal 
inflammation and death ; but no such consequences necessarily attend 
the presence of worms. They may exist at the same time with 
intestinal inflammation or ulceration, as these affections are common 
in strumous, unhealthy children, such as are most subject to worms ; 
and should the bowels be perforated by ulceration, the long round 
worm, if present, will often creep through, and be found in the peri- 
toneal cavity: but this is a consequence, not cause, of the perforation. 

Worms are generally found imbedded in mucus, and a super- 
abundance of viscid mucus in the bowels constantly accompanies 
their presence, and is even looked upon as promoting their forma- 
tion. Worms, however, have been found abundantly where the 
mucous membrane was dry, for want of mucus ; and, according to 
the statement of Andral, we cannot look upon them as necessarily 
causing any morbid change in this membrane, as it was as often pale 
as red, in situations where worms were in contact with it. 

The protracted use of innutritious or farinaceous diet, with little or 
no animal food, and an insufficiency of table salt, or other condi- 
ments, has been assigned as a cause of worms, and apparently with 
good reason. It is remarkable, that while children are so subject to 
worms, infants at the breast are seldom affected with them. Summer 
and autumn appear to be the seasons during which worms most 
prevail. 

Symptoms. — Much as is talked about the symptoms of worms, and 
often as we hear of worm fevers, &c, there are in fact no symptoms 
that truly belong to worms ; nor is there any such disease as worm 
fever. The existence of worms can be unequivocally demonstrated 
only by their having been seen. This subject should now be well 
understood — at least, it is correctly explained in modern works on 
medicine : yet popular prejudice seems to be as inveterate as ever ; 
and even medical men are not always exempt from error on the 
subject. The symptoms which are popularly regarded as indicating 
the presence of worms, are in truth only evidence of irritation of the 
mucous membrane of the intestinal canal ; and this irritation may 
arise from other causes, as the presence of indigestible matter, 
unhealthy secretions, or the existence of a morbid condition of the 



2 3 8 DISEASES OF THE DIGESTIVE ORGANS. 

membrane itself. Indeed, the latter would seem necessary in many- 
instances for the production of any symptoms, although worms were 
present; as they have been passed by children in perfect health, 
who experienced no inconvenience on their account. Even the 
evacuation of worms does not prove that the symptoms present 
were caused by them, though doubtless they are likely to have been 
a°-°ravated thereby : but we must not overlook the fact, that the 
worms may have been but an accidental accompaniment, — a morbid 
condition of the mucous membrane being the true source of the 
symptoms. Hence, the passage of a worm is no reason for blindly 
persevering in the use of anthelmintic medicines ; or pronouncing 
the case cured, because worms were evacuated. It appears, then, 
that all the symptoms commonly attributed to worms may exist 
independently of their presence, and that we cannot be absolutely 
certain of their existence until they have been seen : yet there are a 
group of symptoms which pretty certainly indicate their presence, 
and which, when met with together, should awaken our suspicions, 
and direct attention to the subject. These symptoms may be divided 
into those depending directly on the presence of the worms in the 
alimentary canal, and those connected with the sympathetic relations 
of the digestive organs, and arising symptomatically therefrom. Some 
difference in the symptoms will also be observed, according to the 
species of worm present, or its position in the intestinal tube. 
Worms which are situated in the stomach, or upper tract of the 
alimentary canal, generally cause more severe symptoms, particu- 
larly of the sympathetic kind, than those which are situated lower 
down. 

We do not mean here to give any general account of the various 
species of worms, nor of the numerous symptoms which have been 
attributed to them ; but shall rest content with a notice of the varieties 
most commonly met with in children, and a statement of the symp- 
toms which more particularly characterise their presence. 

Worms may be suspected to be present, when a child looks pale, 
and grows emaciated, while his belly swells and becomes hard, — a 
gnawing, pungent, or twisting pain, being felt in the stomach, or 
about the umbilicus. The appetite is usually precarious, at times 
voracious ; the breath is fetid ; and the bowels often deranged, being 
alternately purged or costive, and much mucus passed in the stools. 
There is commonly picking of the nose : or irritation is felt in the 
rectum : and when a child is old enough, he may at times complain 
of a sense of sinking or faintness, which appears to attend particu- 
larly on the irritation caused by worms. When such symptoms are 
present, and cannot be accounted for by the existence of disease of 
the mucous membrane, or of the mesenteric glands, we have good 
reason for conjecturing that worms are their cause. 

The sympathetic disturbances are not less remarkable than these 
more direct symptoms. Symptomatic affections of the head, are 
among the most serious of those, and the most frequently met with 
in children. Their sleep becomes unquiet ; they are subject to start, 
or suddenly to awaken from slumber ; grinding of the teeth is a 



WORMS. 23g 

symptom often observed ; the eye may look fixed or wild ; the pupils 
are often dilated; there is listlessness, restlessness, or great depression 
of spirits ; pain may be complained of in the head, or convulsions 
attend ; but all these symptoms will often at once disappear on the 
evacuation of some worms ; and such we may consider to have 
caused them, when we observe that the symptoms are not continuous 
as in hydrocephalus, nor yet so intense as in that disease. Worms 
may, however, co-exist with it ; or the sympathetic irritation caused 
by them, pass into inflammatory action. When the child experiences 
a heavy or dull sensation in the occiput, while, at the same time, 
pains in the lower or middle regions of the abdomen are complained 
of, we have a combination of symptoms which in a particular manner 
indicates the presence of worms. The respiratory organs are often 
symptomatically deranged. The breathing may be hurried, oppressed, 
or difficult. The pulse is quickened, or palpitations induced ; and 
the cough, which so often attends, is in general dry, and of a convul- 
sive or suffocating kind. We discover no marks of lesion in the 
lungs, on exploring the chest ; and this gives additional confidence 
in regarding the symptoms as dependent on worms. Vomiting, 
hiccup, diarrhoea, tenesmus, and bloody stools, often accompany their 
presence. 

As to the varieties of worms, we notice first the Ascaris Lumbri- 
coides, or long round worm, which is often met with in children, and 
resides in the small intestines, particularly in the ileum ; but it is liable 
to make its way into the stomach or bowels, and may be ejected by 
vomiting, as well as passed by stool. The lumbricoides* may be 
present without producing any distress, and many of them usually 
exist together ; or they may be found in the same child with the small 
thread or maw worm. The round worm, when it gives rise to symp- 
toms, is in particular liable to cause sharp, colicky pains about the 
navel, and a distressing sense of faintness ; also, great emaciation and 
voracious appetite. 

There are two varieties of thread worm, the long and short ; and 
to these, children in particular are subject. 

The long thread worm, or Tricocephalus, is about two inches in 
length, of a white colour, and like a thread, whence its name. This 
is very commonly met with in sickly children, and inhabits the large 
intestines, particularly the coecum. This worm occurs in great 
numbers, but does not often seem to cause distress ; nor is it attended 
with peculiarities of symptoms. 

The small thread worm — Jlscaris Vermicularis — is very common 
in young children : and also resides in the large intestines, but prin- 
cipally in the rectum. They are called commonly ascarides, and may 
often be seen in great numbers in the stools, looking like bits of cut 
thread ; and, if recently voided, are usually found in rapid motion. 
Hence their name Ascarides ; and hence also, in all probability, the 
great distress which they produce, compared with the variety last 

* This worm is commonly called lumbricus,but erroneously, — this term having 
been applied by Linnaeus to the earth worm. 



240 DISEASES OF THE DIGESTIVE ORGANS. 

mentioned. They often creep from the rectum in children affected 
with them, and may be found in the bed-clothes ; or seen clustering 
around the anus, on separating the nates. The itching and irritation 
felt in the rectum, is a characteristic sign of their presence — this 
sometimes amounts to actual pain ; or they may cause tumours about 
the anus. 

Great sympathetic irritation often attends the presence of these 
worms ; and this is remarkably manifested at the opposite extremity 
of the digestive tube,— -picking of the nose or mouth being a constant 
symptom of their presence. The stomach is also liable to be affected 
sympathetically ; for when ascarides cause irritation in the rectum, a 
sickening or gnawing pain is often complained of in the stomach ; 
and hence, most probably, the term maw worm, by which ascarides 
are sometimes called. The sense of sinking, or faintness, before 
pointed out as often caused by the lumbricoides, also accompanies 
the presence of ascarides in the rectum, when attended by much irri- 
tation ; but the existence of this irritation serves to determine which 
kind of worm is present. 

Other species of worms, as the taenia or tape worm, may occur, 
but those which we have enumerated are the varieties commonly 
met with in children, and to these, therefore, we have confined our 
attention. 

Diagnosis and Progjiosis. — To distinguish between the symptoms 
of intestinal irritation arising from the presence of worms, and from 
other causes, is important ; and when other causes cannot be detected, 
we may presume that they originate in worms, and try to remove 
these. Worms when present, need not give rise to the apprehensions 
that were entertained concerning them of old ; for though fatal con- 
sequences have arisen from them in very young children, such a re- 
sult is rare. Much of the danger formerly connected with worms, 
arose from errors in practice, the sources of which we have pointed 
out, and which need not now be fallen into. 

Treatment. — Little need be said respecting the treatment of 
worms in the child, as this does not differ in principle from the treat- 
ment adopted with adults. Our first object should be, to determine 
how far the symptoms present are connected with worms, or may be 
caused by any inflammatory affection of the intestinal canal. When 
inflammatory symptoms exist, these must be subdued, before we have 
recourse to the exhibition of any irritating substance to expel worms, 
even though we have proof of their presence. We must be guided, 
therefore, in our treatment, by the condition of the digestive organs, 
and avoid injuring them by the injudicious use of anthelmintics; 
which are generally medicines of a very irritating class. Many 
medicines have been proposed as anthelmintics; but those only 
deserve the name, which exercise a deleterious action directly upon 
the worms themselves. Of these substances, some appear to possess 
special influence over one species of worms more than another. 

Purgatives. — Any medicine which acts energetically upon the 
bowels, particularly if it tends to remove accumulations of mucus, is 
calculated to expel worms ; and hence, most drastic purgatives have 



WORMS. 



241 



been in repute as anthelmintics. When we suspect the presence of 
worms, and that the state of the digestive organs admits of the ad- 
ministration of such medicines, the best we can employ is a combi- 
nation of scammony, jalap, and calomel,* to which some strong- 
smelling oil, as oil of juniper, may be added as an aromatic. This 
compound has an extensive range of action through the alimentary 
canal, and is calculated to remove mucus, and act as a brisk cathartic. 
Hence, when worms are present, it seldom fails to cause the expul- 
sion of some, if judiciously persevered in ; and we are thus enabled 
to judge of the species present, and to adopt our measures accord- 
ingly. 

When the small ascarides are present, aloes in particular is pre- 
ferred, from its reputed action on the rectum. In this case, whatever 
medicines we employ may be given with advantage in the form of 
injection. Half a drachm, or a drachm of tincture of aloes, may be 
added to a purgative enema ; and the effect will be enhanced by the 
addition of double that quantity of spirits of turpentine, or some muri- 
ate of soda. As ascarides are not always confined to the rectum, 
aloes may be given by the mouth, as well as by injection. 

In employing purgatives, a principal use is to remove the mucous 
accumulations which form the nidus of the worms, and thus to expose 
those which have not been expelled, more effectually to the action of 
anthelmintic medicines. If purgatives be employed too often, or too 
long continued, they will cause the evil which we wish them to 
counteract ; and, by irritating the bowels, increase the secretion of 
mucus, and debilitate the digestive organs. A purgative, however, 
is generally necessary, after the employment of anthelmintic medi- 
cines, to carry off the worms which they may have destroyed. 

Anthelmintics. — Of the numerous anthelmintics in use, turpentine 
and cowhage are those which we would in particular recommend 
for administration to children. Turpentine acts against all the 
varieties of worms, and may be safely given, even to very young 
children, in doses of half a drachm, or a drachm, and is most easily 
taken when administered in milk. Castor oil may follow as a pur- 
gative ; and this is a better way of giving it, than combining both 
together. The dolichos pruriens, or cowhage, is particularly service- 
able in expelling the lumbricoides and long thread worm. The worms 
generally begin to appear after the second or third dose of the medi- 
cine ; and may then be removed by the aid of a purgative, often in 
great numbers. The medicine is prepared by dipping the ripe pods 
in syrup, into which the pubes or hairs are scraped, until it becomes 
as thick as honey ; and from one to two tea-spoonfuls are given, 
while the child is fasting. If care be taken to have the hairs well 
blended in the syrup, and not to allow the lips to be spattered by the 
medicine, no apprehension need be entertained in giving cowhage 

* Calomel seems to possess some special power as an anthelmintic; and either 
alone, or in combination, may be occasionally given with advantage in the treat- 
ment of worms. We should bear in mind, that calomel enters largely into most of 
the popular worm-powders, and can thus easily understand the destructive effects 
caused by these nostrums when ignorantly administered to children. 
21 



g 42 DISEASES OF THE DIGESTIVE ORGANS. 

to the youngest child ; for though so irritating to the skin, and offen- 
sive to the worms, it produces no effect on the mucous membrane. This 
advantage it shares in common with turpentine ; and the latter is 
even highly advantageous in the mucous diarrhoea which often accom- 
panies worms in children. 

Various bitters have been given as anthelmintics, and such medi- 
cines prove beneficial by restoring the tone of the stomach and bowels ; 
for by invigorating these, worms are often expelled, and their genera- 
tion prevented. The latter object we should never forget. It will 
not be enough to remove worms, unless we take means to restore 
the general health and improve the digestive powers, in children pre- 
disposed to their formation. For this purpose, change of place, or 
residence in a dry, airy situation, is essential. 

The food should be nutritious, or even occasionally stimulant, salt 
being very freely taken at meals. Even as a medicine, muriate of 
soda, whether given by the mouth or by injection, is an excellent 
anthelmintic. 

Diluted muriatic acid has in particular been recommended, for 
restoring the tone of the stomach, and preventing the return of worms. 
For this purpose, however, we rely more on the use of chalybeates ; 
and we have a combination of both in the muriated tincture of iron 
— a preparation which we have found very serviceable. Injections 
of sulphate of iron (from two to five grains in four or six ounces 
of cold water, for a child), we have found particularly successful 
in removing ascarides from the rectum ; and this remedy, though 
long since recommended, is now seldom used. The following elec- 
tuary, which contains iron, is given with great success at the Insti- 
tution for the Diseases of Children, in most varieties of intestinal 
worms. It in general purges briskly, and seldom fails to carry away 
worms, if any be present. 

No. 45. — Eleduar. JLnlhelmint. 

R. Pulveris Jalapae, 
Cry st. Tartar i, 
Carbonatis Ferri, aa. 31. 
l Pulv. Zingiberis, Jss. 

Theriacae, q. s. 
Utft. Electuarium. 
3ss. — 3i* bi s tcrve indies. 

VI. REMITTENT FEVER. 

In classing the infantile remittent fever among affections of the 
digestive organs, we declare sufficiently our opinion of its origin and 
nature : but the disease is in itself very variable ; and according to 
the circumstances which have given rise to it, and the condition of 
the child in whom it occurs, great differences will be observed in its 
course and symptoms. Whatever these differences may be, however, 
we fully concur with those who regard this disease as symptomatic 
of derangement of the digestive organs ; for, as Sir Henry Marsh has 
long since observed,*" its characteristic symptoms, if closely analysed, 

* Dub. Hospital Reports, Vol. III. p. 316. 



REMITTENT FEVER. 243 

will be found all of them to point to the mucous surface as the origi- 
nal seat of morbid action." The nature of this morbid action, how- 
ever, has not been precisely determined, nor can we suppose it to be 
the same in all cases : the most general manner in which we 
can give it expression is by saying, that the intestinal mucous 
membrane is in a state of irritation. It may also be inflamed or 
ulcerated ; but this is by no means a constant condition, as some 
would represent ; and in many instances, these morbid alterations 
arise during the progress of the complaint, or even after convalescence 
has commenced (as happens in continued fever), and must therefore 
be looked upon as a complication, not a cause. 

We have already noticed the tendency which febrile symptoms 
have to assume the remittent type in the child, no matter what be 
the lesion of which they are symptomatic ; but this is particularly 
remarkable in gastro-intestinal disease. Some authors, indeed, speak 
of remittent fevers as being always gastric; and all agree that fevers 
occurring in nervous and feeble subjects (such as infants are acknow- 
ledged to be), show a particular tendency to nightly exacerbations, 
or to assume the remittent type. We have already spoken so fully 
of disorders of the digestive organs in the child, that we feel called 
upon here to curtail much that might otherwise require to have been 
said, both as to the symptoms and treatment of remittent fever, 
although no disease of childhood is of such frequent occurrence, more 
precarious in its progress, or often less amenable to treatment. 

The symptoms of remittent fever may be seen distinctly marked, 
after an infant is one year old, but seldom earlier ; and they continue 
to present themselves in children, until the tenth or twelfth year. 

The duration of the disease is variable, and at all times liable to 
be protracted ; most commonly it lasts from one to three weeks, but 
it may continue for two or three months, and a low form of the com- 
plaint, not unfrequently met with, seldom disappears before the 
fourth week. 

Causes. — The direct relation subsisting between the symptoms of 
remittent fever and irritation of the gastro-intestinal surface, is suffi- 
ciently manifested by the rapidity with which the symptoms are at 
times set up, after the ingestion of over-abundant or unwholesome 
food. Generally, a period of indisposition of a few days' duration 
precedes the full establishment of the fever, which then often sets in 
with much severity — but we have seen it otherwise ; and in one 
remarkable case, where a foreign body (a marble) had been swallowed 
by a child in full health, violent symptoms of fever set in almost 
immediately, assumed the remittent form, and lasted for a few days, 
until the source of irritation was removed, when they as suddenly 
disappeared on the expulsion of the marble. It is thus that purga- 
tives prove beneficial, or hurtful, in this disease. When the symp- 
toms are caused by an overloaded state of the bowels, or the presence 
of vitiated and inordinate secretions, the exhibition of purgatives, by 
unloading the bowels and altering the secretions, is at once necessary 
and useful. Their protracted employment, however, or exhibition 
in cases where the irritation, existing in the mucous membrane itself, 



244 DISEASES OF THE DIGESTIVE ORGANS. 

amounts to a high degree or approaches to inflammatory action, 
must obviously be injurious — as the experience of every day proves, 
when we see remittent fever brought on or kept up by the abuse of 
purgatives. 

The morbid condition of the bowels which gives rise to remittent 
fever may be induced by other causes, besides the use of improper 
food (though this is its most common source); and accordingly we 
find impressions of cold, variations of temperature, or the effects of 
season, and other causes inducing this complaint ; which indeed ap- 
pears at times to spread epidemically, and has by some been looked 
upon as being occasionally contagious. 

We must keep in mind the likelihood there is of meeting with 
remittent fever during the progress of any protracted disorder in the 
child (as hooping cough), and particularly during convalescence from 
the exanthemata. This obviously arises from the proneness of the 
intestinal mucous membrane to take on morbid action under the cir- 
cumstances ; which may be, not a little, promoted by the abuse of 
purgatives so common in the treatment of children's complaints. 

The sudden suppression of a recent eruptive disease, or the quick re- 
moval of a chronic one, is often followed by the symptoms of remit- 
tent fever. The more delicate a child is, particularly if of a strumous 
habit, the more liable is remittent fever to occur, and of course, the 
greater risk is there in the disease when established. 

Symptoms. — Premonitory symptoms are usually present in this 
disease, and may last for several days. The child looks ill, and loses 
his colour ; he is languid or fretful ; complains of pain in the head or 
belly ; is drowsy, but rests badly, starting in his sleep, or grinding his 
teeth. Derangement of the digestive organs early presents itself, and 
is remarkable. The appetite fails, the tongue becomes loaded, and 
the breath offensive. There is thirst, and frequent picking of the 
nose or lips. The bowels are always irregular, often confined ; but 
occasionally diarrhoea attends in the first instance. The stools are 
unnatural, and very offensive ; there is much flatulency ; and all the 
secretions are deranged, especially those of the liver. The urine looks 
milky soon after it-is passed, and deposits a sediment. 

Fever now sets in : or the attack may commence with high febrile 
symptoms, and be ushered in by a cold fit ; nausea and vomiting not 
unfrequently occurring. When once established, the fever is remark- 
able for the distinctness of the exacerbations ; the number of which, 
during the twenty-four hours, varies, however, in different cases. 
There may be, and in general is, but one well-marked exacerbation, 
occurring in the evening, and which lasts till morning, being followed 
by a profuse sweat. The perspiration succeeding to these exacerba- 
tions, however, is not always profuse, and often only partial, being 
Confined to the head or chest; in no instance is it critical. In some 
instances, several exacerbations are to be noticed in the twenty-four 
hours. There are often three, distinctly marked — one in the morn- 
ing, one in the afternoon, and another at night: the latter is gener- 
ally the severest, and that which lasts longest. When the febrile 
symptoms run high, the remissions become scarcely perceptible. " It 



I 



REMITTENT FEVER. 245 

is a singular fact," as stated by Dr. Mason Good, and what we have 
ourselves observed, " that if the exacerbation or increase of fever take 
place in the night, there is wakefulness and perpetual jactitation ; if 
in the day time, drowsiness and stupor." 

However cool or lively the child may be at other periods of the 
day, it always becomes fretful, hot, and heavy, as the exacerbation 
approaches, which usually commences in the afternoon, the child being 
comparatively free from fever in the morning. Occasionally, how- 
ever, the access of fever occurs in the morning, when the child is hot, 
heavy, or stupid, but grows livelier as the day advances. 

During the access of fever, all the symptoms become aggravated; 
and any inflammatory affections which may be present, as inflam- 
mation of the eyes, skin, &c, also undergo exacerbation ; the con- 
junctiva becoming increased in vascularity, or the eruptions greatly 
heightened in colour at this time. The skin, which is, all through, 
dry, now grows very hot, particularly in the palms of the hands, and 
over the abdomen ; parts that are always hotter than the rest of the 
body, especially the latter, which is described as being at times burn- 
ing hot. The pulse rises considerably during the exacerbation, often 
to the amount of thirty or forty beats in the minute above what it 
had ranged before. The respiration is also accelerated, and the 
breathing hurried ; the cough which usually attends the disease 
becomes more troublesome ; and there are occasional palpitations. 
The child is drowsy, and dozes, but does not sleep soundly ; for he 
often moans or talks incoherently, starting in his sleep, or screaming 
out. There is an intense thirst, often incessant, the child calling for 
cold water or sour milk ; but if a large draught be taken at once, 
pain in the bowels is liable to be induced. There is no desire for 
solid food ; and, if forced upon the child, it is frequently rejected by 
vomiting. 

As the period of remission approaches, a perspiration, for the most 
part partial, usually breaks out. During the remission, all the symp- 
toms subside, but none actually disappear. The child becomes more 
lively, and wishes to leave the bed ; or, if sleep should occur at this 
time, it is more natural and refreshing : but the skin still continues 
dry, though perhaps cool ; and the pulse, though lessened in fre- 
quency, is still very quick. As the fever declines, the intermissions 
become lengthened ; while the exacerbations diminish in duration, 
as well as intensity. 

Remittent fever is often less distinctly formed, being milder in its 
symptoms ; but it may be very protracted and variable in its course. 
The child continues ill, appearing alternately better and worse ; it 
looks pale ; its flesh becomes soft, its limbs wasted, and there is a 
great disinclination to move or walk — even pain in the limbs may be 
complained of on the slightest exertion. The skin is hot and dry, 
particularly the hands and belly ; but the feet are often inclined to 
become cold. The abdomen is full and tympanitic, or may be hard, 
and even tender to the touch. The tongue is at first furred and 
white, becoming red at the edges, and soon grows dry towards the 
tip, where a parched spot of a triangular shape may often be ob- 
21* 



24 G DISEASES OF THE DIGESTIVE ORGANS. 

served, as Dr. Mackintosh has noticed. The bowels are always 
much out of order; generally at first confined, but with occasional 
attacks of diarrhoea. The stools are very unnatural and offensive, 
being of a dark brown or red colour, or even bluish, particularly 
when the bowels are costive. When diarrhoea attends, the stools 
are often very white, or green, and are always slimy or charged 
with mucus. At times there is much tenesmus, or only a little 
mucus mixed with blood is passed. The urine maybe of an orange 
colour ; and it has been remarked, that what is passed in the morn- 
ing deposits a sediment, while that passed during the day exhibits 
only a cloudy appearance. As the fever declines, and the skin grows 
moist, the urine deposits a copious sediment, over which it appears, 
itself, of a straw colour. The most remarkable character of the 
urine, however, and that which is oftenest noticed in sick children, 
is the white colour which it so frequently presents. The urine may 
appear white, or turbid, as it is passed ; but more generally becomes 
so on standing, when a copious white precipitate is let fall. This 
is particularly conspicuous, if the child happens to wet the floor, or 
a table, when, on the place drying, a white crust or coating is seen 
left behind. This white deposit is ascribed to a preponderance of 
the phosphates ; and this white or phosphatic uruie is to be looked 
on as a serious symptom, indicating a broken-down state of consti- 
tution, such as we find in ill-fed, sickly children, especially those of 
a strumous habit, and who are suffering under disorder of the diges- 
tive organs. The white appearance of the urine is usually assigned 
as a symptom belonging to worms or to tabes mesenterica : but we 
did not account it such, as it occurs alike in many infantile complaints, 
particularly in remittent fever; and belongs to worms, or mesenteric 
disease, only in so far as they are connected with intestinal irritation, 
or the existence of scrofula. 

Occasionally there is absence of thirst, as well as loss of appetite ; 
so that the child cannot be got to take either food or drink, but lies 
listless, fretful, or drowsy, and appears annoyed at being disturbed. 

Dr. Butter speaks of a variety of the disease, of this description, 
which he calls the low infantile remittent ; but which obviously pre- 
sents that form of the complaint in which there is serious abdominal 
disease, with the head symptomatically engaged. We not unfre- 
quently see a child in whom symptoms of remittent fever set in with 
much severity, but with no peculiarity, except that the cerebral func- 
tions become very early disturbed. The fever, however, soon sub- 
sides, and the child appears to sink, — tying immoveable in bed, 
indifferent to surrounding objects, hardly replying when spoken to, 
and asking for nothing. The disturbance of the nervous system is 
exhibited by frequent tossing of the upper extremities during the 
remissions, though the lower extremities and trunk generally remain 
fixed ; but in the exacerbation, the child slumbers much, yet on being 
roused is sensible. The condition of the digestive organs is exhibited 
by the state of the tongue, mouth, and lips, which are covered with 
sordes ; while there is frequent picking of all parts of the face. The 
urine or stools may pass involuntarily : the latter are very unnatural 



REMITTENT FEVER. 247 

in appearance ; and much pain seems to precede their escape, or that 
of flatus, much of which is usually present. The countenance indi- 
cates distress. — Such is a picture of this variety of the complaint ; 
and in it we recognise the symptoms of a severe enteritic affection, 
in which the head is engaged. 

Diagnosis. — No organ is more liable to become engaged in the 
progress of infantile remittent fever, than the head; and the diagnosis 
between hydrocephalus and remittent fever is often so difficult, that 
some consider it cannot in many instances be made out, until the 
symptoms of hydrocephalus are so unequivocal as to leave little 
benefit to be derived from the discovery. This subject will more 
properly be discussed under affections of the head : but if we keep in 
mind the nature of remittent fever, and recollect how likely we are 
to meet with those sympathetic disturbances of the brain already 
pointed out, as frequently attendant on gastro-intestinal disease, we 
shall be early on our guard ; and by meeting the symptoms of cere- 
bral disturbance as they arise, while we still continue to treat the 
intestinal disease as their origin, we shall be in many instances suc- 
cessful, and in most cases escape forming an erroneous opinion. It 
is in the protracted remittent fever of scrofulous children, in particular, 
that we are to apprehend the supervention of hydrocephalus. Golis 
goes so far as to say that such a termination occurs in those cases, 
six times out of seven. 

The sympathetic affections of the chest may, in like manner, ter- 
minate in inflammatory disease, if not early met by adequate treat- 
ment ; but attention must still be paid to the primary disorder, which 
often appears to be much mitigated on the supervention of the 
sympathetic disease. 

Various eruptive complaints may appear on the skin ; and in some 
instances, pustular eruptions seem to occur in connection with in- 
flammation and ulceration of the intestinal glands. The mouth, nose, 
or face, are frequently made sore from being picked. In these cases, 
the affection of the skin claims little attention, in comparison with 
that of the stomach and bowels. 

Worms may be present in remittent fever, and give rise to many 
of the symptoms ; but if these persist after worms have ceased to be 
expelled, we must treat the case independently of this complication. 
Enlargement of the mesenteric glands is liable to arise, if the case be 
severe or protracted, and this must be borne in mind ; for it is more 
the complications than the disease itself, that give rise to danger in 
remittent fever. In addition to the affections of the intestinal mucous 
membrane, peritoneal inflammation and effusion occur occasionally 
towards the termination of the case, the child becoming affected with 
ascites, or dying anasarcous. 

Prognosis. — When the exacerbations in remittent fever become 
almost incessant, as well as violent, and the abdomen swells, while 
the sympathetic affections increase in severity, great danger is to be 
apprehended. On the contrary, when the remissions become length- 
ened, the appetite restored, and the evacuations improved, returning 
health is to be expected ; and this may be looked upon as near at 



24S. DISEASES OF THE DIGESTIVE ORGANS. 

hand, when the sleep becomes natural and refreshing, the pulse falls, 
the sediment in the urine diminishes, and a general moisture is 
established on the surface. The pulse, however, will often continue 
quick, long after the other symptoms have subsided ; and we must 
never lose sight of the dangers of relapse. 

Treatment. — The principles upon which we conduct the treatment 
of infantile remittent fever must be sufficiently obvious from the view 
which we have taken of the complaint ; the particulars must vary 
according to the condition of the patient, and the period at which we 
see the disease. In a very recent case, obviously induced by an 
indigestible meal, an emetic is often of great service. In a similar 
manner are purgatives necessary, when an overloaded state of the 
bowels is present. We have already alluded to their value, and the 
cautions requisite when administering them (see p. 243). From the 
deranged state of the secretions, the occasional use of a mercurial is 
often very beneficial; and it maybe given combined with an aperient, 
or a diaphoretic, according to the circumstances. The powder of 
jalap, simple or compound, is that which we usually prefer ; and the 
addition of some ipecacuanha (as recommended at p. 128) increases 
the effect. When much permanent heat of skin, thirst, and restless- 
ness, are present, one or two grains of James's powder, joined with 
calomel, or given alone, will best answer to lessen the febrile action. 
Dr. Cheyne recommends this practice, particularly when the sensorial 
functions are engaged ; and we are thence led to apprehend the 
occurrence of hydrocephalus. This termination of infantile fevers, 
Dr. Cheyne thinks, would be less frequent, if bleeding were more 
practised at the commencement of such attacks. Without limiting 
the value of the practice to this point, we certainly would advise the 
use of leeches when the febrile symptoms run high, and the attack is 
recent, as deserving of more general adoption than is now the habit 
in treating infantile remittent fever. Leeches should never be omitted, 
when symptoms of intestinal inflammation are present. These may 
require to be repeated, and should be so when we find that such 
symptoms recur during the progress of the case, but we must keep 
in mind, that increased sensibility of the whole surface sometimes 
exists in this disease, so that the child cannot bear to be touched in 
any part ; and if the epigastrium alone were pressed, this sensibility 
might be taken for abdominal tenderness, and inflammation supposed 
to be present, when such was not the case. After the abstraction of 
blood, a mitigation of the febrile symptoms generally ensues : and 
any medicines then given will more easily produce their effects. In 
particular, mild purgatives will act freely, which had previously failed 
to have any effect. 

The power of the digestive organs upon the food appears often to 
be quite lost during remittent fever, — that swallowed being either 
soon thrown up, quite unchanged ; or passed through the bowels, 
after some time, in a putrid mass, as if it had been subjected to heat 
and moisture, but without having undergone any of the process of 
digestion, as Pemberton has distinctly noticed. Such masses may 
lie in the intestines, and keep up an irritation which we shall in vain 



REMITTENT FEVER. 



249 



attempt to remove, until this matter is expelled, though the symp- 
toms may be mitigated by the use of leeches, &c. Dr. Mackintosh, 
in his Practice of Physic, gives a very instructive case of this descrip- 
tion, in which leeches, &c, produced only temporary relief until a 
mass of indigested food was expelled by the agency of some castor 
oil. Of leeches, then, we may speak as we have of purgatives: 
though each may be occasionally necessary, neither is to be perse- 
vered in as if constituting a cure for this disease. Aperients will, 
however, be oftener required than leeches. 

Refrigerants should never be forgotten in the treatment of remit- 
tent fever. To give cold drinks, and keep the body cool by light 
clothing, and the use of an airy apartment, (while we enjoin quiet- 
ness, and occasionally exclude the light,) is essential to recovery. 
We have used nitre freely in this complaint, and have derived signal 
service from its employment. When the bowels are not irritable, a 
solution of crystals of tartar, given cold in the form of imperial, pos- 
sesses many advantages, as it acts on the kidneys, while it allays 
thirst, and tends to keep the bowels open. In the more advanced 
stages, when debility sets in, we have found the mineral acids use- 
ful ; they can be employed much sooner than quinine ; but the 
latter may occasionally be prescribed at the close of the complaint. 

When much irritability prevails, or diarrhoea is present, the judi- 
cious use of Dover's powder will prove very serviceable ; and 
recourse should be had to the soothing influence of fomentations, or 
the occasional use of the warm bath. 

Attention to diet is an important point in the treatment of this dis- 
ease ; and all we have said respecting regulation of diet, under the 
head of diarrhoea, or inflammatory affections of the bowels, applies 
here : in particular, we must avoid giving such food as is likely to 
leave much residue behind ; and we must be very cautious in allow- 
in 0, any sudden return to the habitual diet, during convalescence. 
At this period, change of air is of essential service, and, indeed, 
throughout the whole management of remittent fever, nothing is 
more remarkable than the benefit derivable from the latter source. 
We have frequently seen a patient who had been several weeks 
labouring under the disease, restored to the enjoyment of tranquil 
and refreshing sleep, the night after his removal to a distance of 
three or four miles from his ordinary abode. 

When diarrhoea is present, it must be treated on the principles 
already laid down ; but in protracted cases, we have found the use 
of turpentine, in particular, of service ; and when this affection be- 
comes chronic, after the febrile symptoms have subsided, we have 
derived much benefit from using the persesquinitrate of iron. 



250 DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTER IX. 

DISEASES OF THE RESPIRATORY ORGANS. 

The infant, like the adult, is subject to inflammations in the dif- 
ferent portions and tissues of the respiratory apparatus, as well as to 
some affections of these parts which are rare, or altogether absent 
in after life. In considering the latter, we shall attempt a complete 
view of their nature ; but with respect to the former, we can only* 
advert to their peculiarities in the young subject, as to character and 
treatment, — our limits forbidding anything like an extended view 
of those diseases which are common to both child and adult. 

I. CATARRH. 

We have seen that the mucous tissues of children are possessed of 
considerable irritability, and are subject to sudden alterations in the 
quantity or quality of their peculiar secretions ; and accordingly, as 
might be expected, simple Catarrh or Coryza is a frequent ailment 
throughout the whole period of infancy and childhood. This affec- 
tion begins with sneezing, watering at the eyes, and discharge of 
mucus from the nostrils. The latter is at first clear, but subsequently 
becomes thick, greenish-yellow, and at length puriform. The child's 
face is flushed ; its skin hot. It sleeps with its mouth open, and 
snuffles in breathing. The latter symptom is often very distressing ; 
and the tumefaction of the Schneiderian membrane may be so great, 
as altogether to prevent the passage of air through the nostrils, and 
so to interfere with sucking, in the young infant. All the symptoms 
just now narrated, may be but the precursors of some exanthematous 
disease, as measles or scarlatina, and, holding that in view, we must 
always be on the watch for the proper eruption. The snuffles may 
exist as a symptom of syphilis ; but we shall, then, have other indi- 
cations of that disease, which shall be noticed under the proper 
head. 

Simple catarrh is not dangerous, and requires little treatment. Any 
cause which may have excited it should be obviated, as draughts of 
cold air, or too much direct light ; the child may be placed in a tepid 
bath, and subsequently kept warm ; and it will generally be advisa- 
ble to administer a gentle aperient, as a little castor oil. 

The affection of the membrane of the nostrils may, however, assume 
a chronic form, and by interrupting the child's sucking may materi- 
ally interfere with its thriving, or even ultimately wear it out. The 
principle of treatment in these cases is, to restore tone to the mu- 
cous membrane, by improving the general health ; and the most 
likely means of effecting this will be, change of air and food, — pro- 
curing for the infant a healthy nurse ; or, if it have a difficulty in 
sucking, supplying it abundantly with asses' milk. We should also 
attend to the surface of its body, and endeavour to promote a healthy 



BRONCHITIS. 251 

condition of it, by sponging once or twice daily with tepid vinegar 
and water. Gentle alterative aperients, as rhubarb combined with 
hydrargyrum cum creta, and a minute quantity of ipecacuan, will be 
found serviceable. Billard recommends from two to four grains of 
calomel to be given, for the purpose of establishing a point of deri- 
vation in the intestinal tube ; and the application of a small blister to 
the nape of the neck, or arm. These means we should only resort to 
when others have failed ; and we would recommend a previous 
trial of iodine, which appears to us to exercise a special tonic power 
upon mucous surfaces.* As a local application, we have found ad- 
vantage from the introduction into the nostrils of a bit of lint wet 
with a decoction of guaiacum wood ; but any means of this nature 
will be badly borne by the young child. Billard describes coryza 
as sometimes resulting in the exudation of a false membrane upon 
the nasal passages, which, in the cases related by him, produced 
death, by obstructing the access of air to the lungs. Such a case 
might require the performance of bronchotomy. 

II. BRONCHITIS — (BRONCHIAL CATARRH). 

Children are very subject to this affection at every age ; and in 
every degree of its intensity. The symptoms are — general fever, 
and restlessness ; with quick pulse ; hot skin, andcostiveness ; or fre- 
quently diarrhoea, with deranged secretions, cough, more or less vio- 
lent ; a mucous rale or wheezing, which may be heard by applying 
the ear immediately to the chest, or may often befell by placing our 
hands flat, upon opposite walls of the thorax ; respiration frequent 
(amounting sometimes to 100 in a minute) ; dilatation of the nares 
during inspiration, and occasionally difficulty in the act of sucking : 
upon percussion, we shall find the chest sonorous throughout, at the 
commencement ; but towards the close it may be dull in some parts ; 
the face may be livid and swollen, or pale and cedematous. In the 
latter stages, each fit of coughing is accompanied by a paroxysm of 
suffocation, ending often in vomiting ; and towards the termination, 
coma or convulsions may supervene. When the disease terminates 
unfavourably, it usually runs its course within eight or ten days : 
when the child is to recover, convalescence generally commences in 
five or six days ; the respiration becomes less frequent, the fever 
abates, and a free secretion being established from the mucous mem- 
brane, the cough becomes looser and less suffocative. 

In young children, the expectorated matters are always swallowed : 
but when we have an opportunity of observing them in older ones, 
we find that they consist at first of transparent mucus, and subse- 
quently of viscid, opake, yellow or greenish, muco-purulent masses. 

The anatomical characters are, increased vascularity of the 
mucous membrane, presence of viscid or purulent mucus in the 
air cells, and engorgement of the lungs with dark-coloured blood. 
Bronchitis, in children, is frequently complicated with pneumonia ; 

* See formula No. 10, p. 102. 



252 DISEASES OF THE RESPIRATORY ORGANS. 

and then we have, as a morbid appearance, hepatisation of the 
lungs, to a greater or lesser extent, and which we have observed to 
be most complete in the lower and posterior portion. This combina- 
tion, or broncho-pneumonia (as it may be termed), frequently occurs 
as a complication of measles and hooping cough, and appears to be 
identical with the disease described by Dr. Cheyne as " the Epidemic 
Peripneumony of Children,"* As in the adult, bronchitis may 
become chronic, and will then closely resemble phthisis. 

The prognosis depends altogether upon the quantity of inflamma- 
tion, and of the accompanying fever: in a previously healthy child, 
the disease is generally under the control of art. 

The treatment may, in common, be more decidedly antiphlogistic 
than would be warranted in the adult (some explanation of which 
may be found in the fact of bronchitis being so frequently compli- 
cated with pneumonia in the child) ; and we shall often be obliged 
to employ general bloodletting by the lancet, or by leeches to the 
hand or foot. When we see the disease early, an emetic of ipeca- 
cuan wine will often quickly cut it short, and will always afford relief 
by causing a discharge of mucus. The administration, then, of one 
or two tea-spoonfuls of the medicine just mentioned, every ten or 
fifteen minutes, until vomiting is produced, is very often our first 
step ; but should the fever and difficulty of breathing be considerable, 
with hot skin, and the pulse not very feeble, we must at once bleed. 
From two to four ounces, during the first two years, will commonly 
be a sufficient bleeding ; but it must be carried far enough to make 
an impression on the system, which in young children we can always 
judge of by their lips becoming pale. It may be necessary to repeat 
the bleeding, if the symptoms which called for it at first, should re- 
turn ; but if a suitable quantity of blood be taken in the beginning, 
this will not often be the case. When the bowels are confined, or 
the secretions depraved, we must administer an aperient or altera- 
tive, as the powder of jalap and ipecacuan, No. 31, p. 12S ; but it is 
decidedly injurious to carry purging to any considerable extent in the 
treatment of bronchitis. Indeed, so intimate in children is the sym- 
pathy between the gastric and bronchial mucous membranes, that 
we have frequently seen all the symptoms of bronchial catarrh kept 
up, long after the inflammation had ceased, by irritation produced in 
the intestinal tube by over-purging. 

Next to bloodletting, the most powerful means of checking bron- 
chitis is, undoubtedly, tartar emetic ; and we shall often find great 
advantage to result from their combined employment. After the 
immediate effects of bloodletting have subsided, should the fever and 
dyspnoea not be materially relieved, we may administer a solution 
containing from the eighth to the fourth of a grain of tartar emetic 
(according to the age of the child) every hour, until vomiting or 
faintness be produced ; and by this means we shall often save the 

* Pathology of the Membrane of the Larynx and Bronchia. By J. Cheyne, 
M.D. Ed. 1809. See also, Observations on the Peripneumonia of Children, by 
Thomas Cuming, M.D., in Trans. Association K. and Q. Coll. of Physicians, vol. v. 



BRONCHITIS. 



253 



system the expense of a second bleeding. In the advanced stages, 
tartar emetic will frequently fail of producing any effect, and we 
think had better not be given except in cases indicating, or almost 
indicating, bloodletting. 

After the employment of tartar emetic, or in conjunction with it, 
the warm bath will frequently be of decided benefit ; but it must be 
confined to the lower extremities of the child. The pelvis and legs 
alone must be immersed, by which plan a derivative effect appears to 
be produced ; while the general warm bath excites the circulation, 
and always does harm. The heat of the water should be from 98° 
to 100°, and the child should not be left in it longer than ten or fif- 
teen minutes. 

When the disease has been neglected at the commencement, or 
has not been cut short by such active treatment as we have recom- 
mended, we often find that considerable debility sets in, at the same 
time that a profuse secretion is taking place from the mucous mem- 
brane. Under such circumstances we must not bleed, as the stage 
for arresting the inflammation has then passed, and strength is re- 
quired to throw off the secreted matters, and to enable the system to 
hold out until resolution be accomplished. In this stage, we have 
found advantage from the use of calomel and ipecacuan, in doses of 
from a sixth to half a grain of each, every second, third, or fourth 
hour ; these medicines often acting without producing any sensible 
evacuation, although they occasionally cause vomiting and purging. 
When the bowels are in an irritable slate, it will be well to combine 
a grain of compound-chalk powder with each dose. 

It is at this period also that we meet an opportunity for the appli- 
cation of blisters, when the skin is becoming cool, and the system 
obviously in need of a stimulant ; but for reasons explained in a 
former chapter, we must never allow one to remain on longer than 
three or four hours. The best situations for blisters are the front of 
the chest, or between the shoulders. We have often seen great 
benefit produced by them when employed at the proper time, and 
have, in many instances, observed the bronchial symptoms to sub- 
side altogether, simultaneously with the setting in of gangrene in 
the blistered part. In these cases, however, the cure is most com- 
monly purchased by the death of the patient from the new affection. 

We have not yet spoken of the use of expectorants. During the 
early stages, nothing of the kind is admissible, beyond the emetic 
medicines we have recommended. In the latter part of the stage of 
debility, however, stimulants will be required, and we may then join 
them with expectorants, e. g. — the decoction of polygala may be 
given every three or four hours ; and ammonia or squill may be re- 
sorted to, according to one of the formulas at p. 115. When the 
child is much weakened, white wine whey may be given in quan- 
tities of a tea-spoonful every hour, or half hour. But when these 
measures are called for, the time for curing the disease has, in all 
probability, passed away ; and we cannot too explicitly caution 
the practitioner to meet it promptly and judiciously upon its first 
approach. 

22 



254 



DISEASES OF THE RESPIRATORY ORGANS. 



The regimen in the early stages should be antiphlogistic. Infants 
often snck greedily at the commencement ; and Dr. Cheyne recom- 
mends the breast to be withheld, and water, or thin gruel, sweetened 
or mixed with a small quantity of the breast milk, to be given in- 
stead. Older children should certainly get nothing but mild fluids, 
as barley-water or whey, during the early stages. During the pro- 
gress of convalescence a nutritious diet will be required, but it must 
be of the lightest and least stimulating kind. Infants will need 
nothing beyond a plentiful supply of breast milk. 

The temperature of the child's apartment should be equable, and 
moderately warm ; but free ventilation should at the same time be 
secured. In the latter stages change of air, even from one room to 
another, when it can be accomplished without much exposure, will 
often do signal service. 

' III. PNEUMONIA. 

We have stated that pneumonia frequently exists as a complica- 
tion of bronchitis, and our observations lead us to doubt much if it 
ever occurs in young children as a primary idiopathic affection. 
This view may be attributed to the difficulty of recognising the dis- 
ease in infancy and childhood, and the insufficiency of the physical 
signs, at these periods of life, to the establishment of an accurate 
diagnosis between bronchitis and pneumonia. In cases in which 
post-mortem examinations disclosed to us unquestionable results of 
pneumonia, the disease had commenced with the symptoms of bron- 
chitis detailed in the last section. There was mucous, but not crepi- 
tant rale, and no distinct bronchial respiration. Any information 
to be derived from the sputa, was, of course, wanting, as children 
seldom or never expectorate ; and percussion commonly gave a 
dull sound on both sides, the induration seldom being limited to one 
lung. 

According to the observations of Dr. Gerhard,* children above six 
years of age are subject to pneumonia, with characters precisely 
similar to those which the disease presents in adults ; but, previously 
to that age, it is very different in symptoms and progress, occurring" 
mostly as a secondary lesion. Of forty cases which he noted in the 
Children's Hospital at Paris, of patients between the ages of six and 
sixteen, exhibiting the true signs and symptoms of pneumonia, but 
one terminated fatally ; while of sixteen patients between two and 
six, " who seemed attacked with pneumonia," twelve died, and pre- 
sented a greater or lesser degree of hepatisation of both lungs. Dr. 
G.'s experience, therefore, may be considered as not opposed to our 
own.t 

M. Billard, also, conceives that the pneumonia of infants always 

* American Journal of Med. Sciences, vol. xiv.-xv. Philadelphia, 1834. 

f M. Berton expresses similar opinions, considering- pneumonia in children to be 
frequently complicated or secondary ; he also particularly mentions the difficulty of 
its diagnosis by means of the physical signs. Traite des Maladies des Enfans. 
Paris, 1837. 



PLEURITIS — CROUP. 255 

arises from a stasis of the blood in the lungs, acting in some sort as 
a foreign body, and that it possesses characters really different from 
those of the disease similarly named in adults; but he subsequently 
states, as an argument against the use of expectorants, that the bron- 
chi frequently take no part in the inflammation. 

From the views we have just put forward, it must be obvious that 
we can have little to add, either with respect to the symptoms or 
treatment of pneumonia in children, to what we have advanced 
when treating of bronchitis. If the disease be met with and recog- 
nised in young children, as a primary affection, it must be treated 
upon the principles laid down for the first stage of bronchial inflam- 
mation ; and a suitable management of that morbid condition will 
be the best means of preventing the appearance of pneumonia as a 
lesion secondary to it.* 

IV. PLEURITIS 

Is occasionally discovered upon the post-mortem examination of 
children, but there are no diagnostic marks which distinguish it from 
other inflammations of the chest during life — " the integrity of the 
cry" mentioned by M. Billard, being altogether insufficient for dia- 
gnosis. This is of the less consequence, however, as the treatment 
must be similar to that of any other inflammatory affection of the 
chest. There does not appear to be much tendency to pleuritis in the 
young subject, as we do not meet with traces of it in their bodies 
nearly so often as in those of adults. 

We may mention here that Pericarditis may be shown by morbid 
appearances to have existed in young children ; but as the discovery 
of it during life, in such patients, can in the present state of our know- 
ledge be only a guess ;t and as its treatment must be identical with 
that of the inflammations we have been just considering, it would be 
out of place to notice it at greater length. 

v. CROUP. 

Cynanche Trachealis, Angina Membranacea. — This disease may 
be said to be peculiar to childhood, being most common between the 

* MM. Rilliet and Barthez observe, that in almost all the cases of pneumonia 
in children, treated by them, and which terminated favourably, the improvement 
commenced between the seventh and ninth days, whatever might have been the 
treatment, or even when no treatment was adopted. Maladies des Enfans .• Affections 
de Poitrine. Paris, 1838. [Note to 4th Edition.] 

f A case remarkably corroborative of this statement was related, by Professor 
Benson, to the Surgical Society of Ireland, during its present session. A child, 
five months old, died after an illness of eight days, during which period it was 
treated by three medical men of experience. The illness was chiefly indicated by 
screaming. On examination, after death, a large quantity of fluid was found within 
the pericardium ; the surface of which and of the heart were coated with a thick 
layer of lymph ; the walls of the left ventricle, when divided, presented an unusual 
thickness ; where the lung lay in contact with the diaphragm there was some 
lymphy exudation, but there was no pneumonia. See Medical Press, vol. iii. p. 38, 
[Note to 3d Edition,] 



256 DISEASES OF THE RESPIRATORY ORGANS. 

first and eighth years, and scarcely ever occurring after puberty. It 
consists of an inflammation of the mucous membrane of the larynx, 
trachea, and bronchial tubes, usually ending in the formation of a 
membranous concretion upon the internal surface of those parts. 

The predisposing cause of croup is considered by Dr. Cheyne to 
be the imperfect state of development of the organs of voice, there 
being scarcely any perceptible difference between the aperture of the 
glottis of a child of three and one of twelve years of age ; while, after 
puberty, that opening is suddenly enlarged, in the male, in the pro- 
portion of ten to five, and in the female, of seven to five : thus, at 
least, marking the limit of the period of occurrence of the affection. 
There appears to be a remarkable predisposition to the disease in 
certain families, many children of the same parents being affected 
with it at different times. It is also observed to be endemic in certain 
situations, especially in the neighbourhood of seaport towns, and 
about the mouths of large rivers, where the inhabitants are exposed 
to the effects of a damp, alluvial soil, and moist atmosphere, and at 
the same time usually suffer the privations incident to a dense state 
of population. 

When a child has been once affected with croup, it must be con- 
sidered as liable to a recurrence of the disease, at any period until 
the arrival of puberty. Infants at the breast are less liable to be 
attacked than those who have been weaned; but Dr. Home has 
observed that an early weaning renders children more liable to the 
disease. It may occur at any season of the year, but its most common 
period is in the end of winter and spring, and during the prevalence 
of north and north-easterly winds. 

Symptoms. — Croup is sometimes preceded, for two or three days, 
by symptoms of a common catarrh, attended usually with hoarseness 
and a rough cough. We can never be too early in our recognition 
of the more dangerous affection, — and, accordingly, we should look 
with suspicion upon the two last-named symptoms, especially when 
we have reason to dread any predisposition, local or hereditary, to 
croup. Occasionally there are no premonitory symptoms whatever, 
the attack taking place during the night, after the child has, perhaps, 
passed an evening of unusual gaiety, and exercise in the open air. 

The approach of the disease may then first be indicated, and alarm 
excited, by the child giving, during sleep, the unusual cough which 
is so well known as one of its most characteristic symptoms. It is a 
single cough, sharp and ringing, as if it passed ' through a brazen 
trumpet/ — and when once heard and recognised, will not easily be 
forgotten. When the child awakes, which soon happens, his voice 
will be observed to be sharp and striduious; his breathing audible, 
difficult, and laboured, and often accompanied, during inspiration, 
with a crowing sound. He is obviously suffering great distress ; the 
face is swelled and red ; the eyes suffused ; the skin hot ; pulse quick 
and hard ; if old enough, he complains that he is choking, and 
eagerly asks for drink ; if younger, he tosses about restlessly, and 
frequently grasps at his throat, as if anxious to remove some obstruc- 
tion to respiration. The ringing, solitary cough continues at inter- 



CROUP. 257 

vals. In a few hours the disease, though unchecked by treatment, 
may appear to subside, and an interval of comparative ease may 
ensue. This is, however, commonly but a remission; and if the 
affection be not cut short in its first stage, the respiration becomes 
more and more laboured and wheezing; the cough hoarser and 
suffocative ; the voice stifled ; the countenance pale, or livid. The 
debility of suffocation then sets in — the extremities become cold; 
the skin clammy ; there are dark and fetid stools ; coma or convul- 
sions supervene ; and the patient dies between the third and fifth 
days. In the latter stages, the child, if old enough to expectorate, 
may cough up purifcrm matter, and portions of a whitish membranous 
substance. 

In some cases croup may assume a more chronic form, and be 
protracted for two or three weeks. In others, the fatal event may 
take place early, in consequence of a spasmodic paroxysm of dyspnoea 
occurring, and continuing long enough to destroy life by suffocation. 
During a paroxysm of this description, it has been observed that the 
head will be occasionally thrown back, so as to stretch the trachea, 
and that such a posture will afford temporary relief. 

The auscultatory signs in croup (independent of the peculiar 
cough, and crowing respiration), indicate inflammation of the air 
cells, and sometimes of the substance of the lungs. We have at first 
a mucous, and subsequently a sibilant rale. Upon percussion also, 
we may have a dull sound throughout a greater or less extent of the 
chest. When the false membrane is partially detached, we may 
have a clapper or valve-like sound, upon inspiration, when the upper; 
and upon expiration, when the lower extremity of the membrane is 
detached, and moved by the passage of the air through the larynx. 

The anatomical characters of croup are redness and swelling of 
the mucous membrane of the larynx, trachea, and bronchi — all of 
which, especially the two former, may be lined with a yellowish 
membranous substance, which sometimes assumes a tubular shape, 
and at others exists in detached portions. This is the membrane of 
croup. Bat the disease may terminate fatally before its formation, 
and we shall then find the mucous membrane of the larynx red and 
swollen, and perhaps covered with a yellowish, viscid fluid. The 
trachea commonly contains a reddish serum, which is also found in 
abundance in the air cells and parenchyma of the lungs. Sometimes 
there is even hepatisation to a considerable extent, and the pleura 
may share in the inflammation. 

These characters explain the course of the disease, in which there 
is — inflammation and effusion, accompanied by difficult and imper- 
fect respiration, and causing a circulation of blood not revivified ; 
loss of sensorial power ; and death. The occasional occurrence of 
a suddenly fatal exacerbation, after a remission of the symptoms, Dr. 
Cheyne refers to a valve-like closure of the tracheal tube by a portion 
of the membrane which has been partially detached, and the pro- 
duction thus, of instant suffocation. 

Diagnosis. — Other species of cynanche may simulate croup — e.g., 
cynanche maligna, or (to use a different nomenclature) diphtherite 
22* 



#58 DISEASES OF THE RESPIRATORY ORGANS. 

may extend into the upper opening of the larynx, and produce croupy 
breathing, &c. This disease is to be distinguished from genuine 
croup by the existence of aphthae, or sloughs, or of a membranous 
concretion upon the fauces : these never exist in the latter affection. 
Cynanche pharyngea, or inflammation of the pharynx, may also be 
distinguished by the inflammation of the fauces, and difficulty of 
swallowing proper to it. Measles sometimes assume the features of 
croup upon their first attack ; the catarrhal symptoms of that dis- 
ease occasionally assuming a croupy character. The diagnosis can 
only be established by the appearance of the characteristic eruption, 
when it is probable that the doubtful symptoms will subside. Hys- 
teria may occasionally present, as one of its features, the characteristic 
cough and breathing of croup ; but the former disease is not of fre- 
quent occurrence before puberty, and the latter seldom appears after 
that period ; so that they are not likely to be confounded. 

Every affection of the larynx is subject to exacerbations, which 
partake much of a spasmodic character ; and, as we have already 
stated, a paroxysm of this nature may occur at an early period of 
true croup, and destroy the patient before there has been time for any 
very important results of inflammation to be produced. Similar 
paroxysms have also been observed without previous or sub- 
sequent symptoms of inflammation, and have subsided without 
active treatment ; so giving rise to the notion that there existed a 
distinct form of Spasmodic Croup. There are, however, no means 
of distinguishing between the two affections, (if two distinct affections 
exist,) beyond the degree of violence of the symptoms. Whenever, 
therefore, we meet with the symptoms already enumerated, as indi- 
cating the onset of croup, we should be upon the alert ; and as soon 
as any permanent difficulty of breathing sets in, we should forget all 
hypotheses of the spasmodic nature of the disease, and treat it as an 
active inflammation, persuading ourselves, like Dr. Kellie, " that 
there is truly no essential difference between them (spasmodic and 
inflammatory croup), other than what arises from degrees of violence, 
and the obvious circumstance of intermission and continuance."* 

Prognosis. — Croup is always a dangerous disease, even under 
the most favourable circumstances ; but it is also one which admits 
of the use of decisive means, and is thereby remarkably within the 
control of art. When we see a patient, then, at an early period of 
the disease, we may hope to be able to relieve him; but still our 
prognosis should always assume a doubtful tone. 

Treatment. — From the view we have taken of the nature of 
croup, it must be obvious that we are prepared to recommend a 
strictly antiphlogistic treatment and regimen ; and, in truth, no other 
plan can be relied upon throughout the disease. When we find a 
child affected with the ' ringing cough,' especially if it belong to a 
family subject to croup, we should at once place it upon a dimi- 
nished allowance of non-stimulating food, confine it to the house, 
and administer a drachm of ipecacuan wine, or of the antimonial 

* Letter in Cheyne's Pathology of the Larynx and Bronchia. 



CROUP. 25 g 

mixture, recommended at p. 112, every hour or two, until nausea be 
produced ; and this we should keep up for ten or twelve hours. We 
may, at the same time, apply to the throat a flannel bag filled with 
hot salt, as recommended by Mr. Kirby,* a measure which we have 
found to act most beneficially as a rubefacient, and by bringing out 
general perspiration. By adopting these means, we may often 
anticipate and prevent a seizure of croup. 

Let us now suppose that fever and difficulty of breathing exist, 
together with the other symptoms denoting that the disease has ac- 
tually commenced — under these circumstances the first principle to 
be held in view in our treatment, is obviously to subdue the inflam- 
mation, and obviate the tendency, which the mucous membrane of 
the child possesses, to the production of a membranous concretion. 
Our most powerful means of working out this principle is bloodlet- 
ting ; and this should be immediately performed by opening a vein 
in the arm or hand, or (if we cannot get sufficient blood from these), 
the jugular vein. Enough of blood must be taken to produce an 
effect on the system : under two years of age, from two to five 
ounces ; under the eighth year, from three to eight ounces — will pro- 
bably do what we require, at least for the time. 

Mr. Porterf judiciously observes, that " it is not sufficient to dimi- 
nish an increased action, unless the constitution be kept, until the 
period of danger is over, in a condition that will render a renewal 
of that action unlikely to occur." Now, the best means of effecting 
this object is, simultaneously with the bleeding, to place the system 
under the influence of nauseating medicines ; and, accordingly, if 
Ave have an emetic at hand, it will be well to give it shortly before 
bleeding, so as to cause the abstraction of blood to be made while 
the state of nausea is commencing. Thus we shall often produce, 
at a small expense to the constitution, a degree of depression suffi- 
ciently complete to overcome the disease ; and this must be kept up 
until the fever, hurried respiration, and other symptoms of danger 
disappear. To keep up the state of debility, a drachm of the tartar 
emetic mixture, prescribed at p. 112, must be given sufficiently often 
(/. e., every half hour, hour, or second hour), to maintain a continued 
nausea. While this is being done, the lower extremities of the child 
may be placed for ten or fifteen minutes, in a warm bath at the tem- 
perature of 98° to 100° F. and two or three grains of calomel given 
every third hour. The calomel we would expect to move the bowels 
after the second or third dose ; and if it then fails to do so, a drachm, 
or two drachms, of castor oil should be given. Mercury has been 
recommended as a substitute for bloodletting in the treatment of 
croup ; but it should never be solely trusted to, in the first stage of 
an acute attack. If the disease be violent, one bleeding will often 
be sufficient ; but whenever reaction takes place, we must have re- 
course to a second. In severe cases, it may even be necessary, in a 



* Dub. Med. Jour. vol. viii. 

f Observations on the Surgical Pathology of the Larynx and Trachea. Dublin, 
1826. 



260 



DISEASES OF THE RESPIRATORY ORGANS. 



strong child, afterwards to apply leeches to the sternum (never to 
the throat, for the reasons specified at p. 105), always proportioning 
the depletion to the strength of the child, and to the continued vio- 
lence of the acute inflammatory symptoms. 

[In violent and apparently desperate cases of croup, a tobacco 
cataplasm, composed of the moistened leaves of tobacco mixed with 
the crumb of stale bread or ground flaxseed, and applied around the 
throat, has occasionally been found beneficial. The effects of the 
cataplasm should be carefully watched, lest its depressing effects be 
carried too far. — C] 

When the active measures recommended have been judiciously 
employed in the commencement, we shall often have the satisfaction 
of finding that the respiration becomes less laboured, the cough loose, 
and that the fever abates ; and we then know that our treatment 
has been, so far, successful. We must still, however, most carefully 
watch against the dangers of a relapse, strictly enjoining an anti- 
phlogistic regimen, and directing the utmost vigilance towards any 
return of the symptoms. 

When we have been unable to control the disease, or it has run 
into its second stage before assistance has been obtained, our principle 
of treatment is somewhat different. We have still an increased vas- 
cular action to reduce and modify, but we have also to combat the 
effects of that action in the production of a false membrane in the 
larynx and trachea, and of congestion in the lungs and, in the more 
advanced periods, in the brain. The time for bleeding, therefore, 
which should be considered rather as a preventive than a cure of in- 
flammation, has passed away ; and we must not, by its use, perma- 
nently reduce the strength of the patient, when all his resources will 
be wanting to carry him through a protracted, but natural effort at 
recovery. 

At this period, Dr. Cheyne recommended the continued use of anti- 
monial emetics ; and it is from their employment, certainly, that we 
would hope for most benefit. The emetic may be expected to relieve 
the respiration, by aiding in the removal of the effused fluid from the 
bronchial tubes ; and the continued, nauseating effect of the antimony 
will offer the best chance of reducing and altering the morbid condi- 
tion of the diseased parts. Half an ounce of the antimonial mixture 
should be given every half hour, until vomiting be produced ; and in 
two or three hours after the last act of vomiting, the same process is 
to be recommenced, and so repeated while the strength will admit. 
A remarkable tolerance of the medicine will often be produced, so 
that several grains of tartar emetic will be taken without causing 
any effect. The only cases which Dr. Cheyne saw recover from the 
second stage of croup were those in which the patient was kept under 
the influence of the medicine for two or three days. 

It is in the second stage of croup that calomel may be looked to as 
likely to produce a useful effect, beyond what depends upon its pur- 
gative quality. This medicine appears to possess, in many cases, the 



INFLAMMATION OF THE LARYNX. 2 61 

effect of equalising and quieting increased local vascular action ; and 
we may, therefore, rationally employ it in the second stage of croup, 
in conjunction, ho we ver, with antimonials. If we look for any advantage 
from its use, we must give it in doses of two or three grains every 
second or third hour. Blisters also may be applied to the sternum 
in the second stage of croup ; and we would recommend their use in 
this disease to be always directed towards the relief of the lungs, 
rather than of the larynx. We shall thus be prevented from ever 
thinking of applying them to the throat, where they create intolera- 
ble annoyance, on account of the restlessness of the child, and are, 
moreover, too near the actual seat of inflammation to have any effect 
except that of keeping it active, 

In the latter periods of the second stage, when the child is cold and 
sinking, we must have recourse to wine, or even burnt brandy, or 
ammonia ; but these are only to be used when all other remedies 
have been employed to the utmost verge that prudence will permit. 
Children, however, have recovered, under their use, from the most 
hopeless condition — and we should never despair of a sick child. 

It has been proposed to perform the operation of bronchotomy in 
croup, with the objects — first, of admitting air to the lungs without 
the intervention of the larynx ; and, secondly, of removing, mechani- 
cally, the false membrane from that passage. We have already 
stated that the inflammation of croup is not confined to the larynx, 
but extends over the whole bronchial mucous membrane ; and Dr. 
Cheyue has shown that, in fatal cases, a space of more than two- 
eighths of an inch usually exists in the larynx, for the transmission 
of air. The patient, therefore, except in cases of sudden spasm, dies, 
not because air cannot have access to his lungs, but because these 
organs are unfitted, by their inflamed condition, from performing 
their own function. Consequently, bronchotomy is unnecessary for 
the effecting of the first object, and can do no good. As to remov- 
ing the false membrane, if it could be accomplished, which those who 
are familiar with the morbid appearances in croup will doubt, the 
same ultimate objection applies, viz. — that we still have the diseased 
condition of the lungs remaining, and to the removal of that, we con- 
tribute nothing by opening the windpipe^; but, on the contrary,add a 
new cause of irritation. 

Prophylaxis. — We have stated that croup appears to be endemic 
in low, damp situations, near the sea or large lakes ; and from such 
places a child who has once suffered the disease, or belongs to a family 
predisposed to it, should be removed. He should, also, be carefully 
and sufficiently clothed, and as little as possible exposed to the influ- 
ence of cold and damp, or easterly or north-easterly winds. 

VI. OTHER INFLAMMATIONS OF THE LARYNX, INCIDENT TO CHILDREN. 

The disease commonly known under the name of Laryngitis or 
Angina OSdematosa, is one rather of advanced life than of child- 
hood ; but there are some other inflammatory affections of the larynx, 
which belong more especially to the latter period, and therefore call 
for notice here. 



2Q2 DISEASES OF THE RESPIRATORY ORGANS. 

One of the most common of these is the inflammation arising from 
the attempt, occasionally made by children, to drink from the spout 
of a kettle containing boiling water. In these cases, the common 
effects of a scald are produced upon the mouth, fauces, epiglottis, 
pharynx, and oesophagus, varying in degree according to the quan- 
tity of heat applied, either in the shape of steam, or by the boiling 
water itself. The symptoms are dyspnoea, resembling that in croup ; 
audible inspiration ; stifled voice ; usually accompanied with the 
sinking and debility which commonly attend severe burns and scalds, 
and are strikingly manifested in a sunken countenance, cold extremi- 
ties, and tendency to coma. The local appearances vary somewhat : 
there may be extensive inflammation and vesication of the tongue, 
cheeks, and fauces, with partial removal of the cuticle ; or the parts 
may appear, as in Dr. Burgess's case,* as if a piece of raw meat was 
thrust into the fauces ; the epiglottis is generally swollen and blis- 
tered, or as it were, corrugated. Upon examination after death, 
there has been lymph observed in the trachea, in some cases ; in 
others, the inflammation has not appeared to descend below the larynx. 
The former will more usually be observed in patients who have sur- 
vived the accident for some days, and then marked traces of violent 
inflammation of the lungs will frequently coexist. The oesophagus 
and stomach usually escape uninjured. 

These are cases in which we should, d priori, suppose that bron- 
chotomy would be required, and be likely to succeed, as the obstruc- 
tion is usually confined to the larynx ; the trachea and bronchi 
being, in the first instance, sound. Much success has not, however, 
attended the operation, probably in consequence of the severity of 
the accident producing a shock which the system is unable to bear. 
Dr. Burgess, of Clonmel, operated twice, and with success in one in- 
stance.t Dr. M. HallJ recommends scarifying the epiglottis, for the 
purpose of reducing the swelling, and the suggestion certainly deserves 
to be remembered. 

With respect to general treatment, that suggested by Dr. Cheyne — 
viz., the administration of small doses of opium every two or three 
hours — appears to be the most rational, as being likely to allay irri- 
tation, and support the system under the shock which it has sustained. 
Dr. C. places no great confidence in bleeding ; and in thinking of this 
remedy, we must recollect that in accidents of this kind a sudden im- 
pression upon the nervous system is produced, which makes them 
different from ordinary inflammations, and appears generally to con- 
traindicate bloodletting. Small quantities of soothing fluids, as almond 
emulsion, or cream, should be constantly placed in the mouth ; and 
perhaps cream-ice, used in the same manner, might be of service. 
When the difficulty of respiration is so great as to threaten death, 
bronchotomy should certainly be performed without loss of time. 

* Dublin Hospital Reports, vol. iii. 

t For the particulars of a case of this kind in which tracheotomy was success- 
fully performed by Mr. Smyly, see the Medical Press, vol. ii. p. 320. [Note to 3d 
Edition.) 

$ Med. Chir. Trans, vol. xiL 



FOREIGN BODIES IN THE LARYNX AND TRACHEA. 2 63 

Inflammations originally affecting the fauces may extend to the 
rima glottidis and larynx ; and in this way death is often suddenly 
caused by the obstruction occasioned to respiration, although the pri- 
mary disease was not one, of the proper air passages. Thus, in small-pox, 
pustules may be formed upon the parts in question ; and in scarla- 
tina or diphtherite, aphthous ulceration ; or a false membrane may 
descend into the windpipe. In the treatment of those diseases, a 
great deal of attention must accordingly be paid to the state of the 
air passages ; and it is to be recollected, that our great object must 
be, to prevent the affection from extending to these parts, as we 
have but little control over it when so much progress has been made. 
The diseases alluded to, are considered under their proper heads. 

In some of these secondary affections of the larynx, we have had 
occasion to observe how inadequately the symptoms or morbid ap- 
pearances explain the effects produced. We once attended a child 
in small-pox, which went favourably through the disease up to the 
filling of the pustules ; and, upon the last occasion of our seeing it 
alive, cried without hoarseness, and appeared to be going on as well 
as could be desired under the circumstances. In about four hours 
afterwards, a spoonful of water was placed in its mouth, which was 
rejected through the nostrils ; and, without cough or convulsion, 
death instantly took place. The only remarkable morbid appear- 
ance was a dotted abrasion of the margin of the rima glottidis, — 
the part appearing, precisely, as if small portions of the mucous 
membrane had been cut off in dots with a sharp instrument. The 
lesion did not resemble ulceration, but rather that abrasion of the 
conjunctiva of the eye which we sometimes see in strumous children, 
the cornea beneath remaining clear. There were no pustules upon 
or near the epiglottis ; nor any appearances in the brain sufficient to 
account for death.* We mention this case for the purpose of show- 
ing how apparently slight a cause may produce, in children, sudden 
and most unexpected dissolution. 

VII. FOREIGN BODIES IN THE LARYNX AND TRACHEA. 

Children are very liable to obstructions of the respiratory function 
from this cause ; and as the diagnosis of such a case is difficult and 
important, it is necessary that we should notice it, although the sub- 
ject does not especially belong to the province of the child's physician. 
The affections with which we are most likely to confound accidents 
of this kind are, hooping cough, spasm of the glottis, and croup ; 
and, in fact, many of the symptoms are those belonging to the latter 
disease. 

The child will be suddenly attacked with a paroxysm of difficult 
breathing and spasmodic cough, so severe as to threaten instant suf- 
focation, — the dyspnoea being greater during expiration than inspi 

• A case similar to the above, so far as the rima glottidis was concerned, was 
read by Dr. Falloon before the Surgical Society of Ireland: but in it there were 
symptoms resembling croup, and the dotted ulceration extended into the trachea 
and bronchi. 



264 



DISEASES OF THE RESPIRATORY ORGANS. 



ration. These paroxysms recur at intervals, during which the child 
will probably breathe hoarsely, bat may in other respects appear 
tolerably well, During one of the paroxysms, the foreign body 
may be forcibly expelled from the mouth, when the symptoms will 
shortly cease ; but if the case continue without relief, bronchitis will 
probably ensue, and the patient perish from that disease, or by sud- 
den suffocation. 

The means of diagnosis chiefly to be relied upon, are the history 
of the case, and the stethoscopic signs. If a healthy child has been 
suddenly attacked with spasmodic cough whilst eating, or playing 
with some small article (as a bead, button, &c.) which has simulta- 
neously disappeared, a presumption is afforded that some foreign 
substance has got into the trachea. The stethoscopic signs are 
chiefly valuable at the commencement, before inflammation of the 
bronchi has set in. When the foreign body is fixed in the larynx, 
as is likely if it be a fish-bone or other pointed substance, the healthy 
respiratory murmur will be plainly distinguishable throughout the 
whole extent of the thorax, which will also return a clear sound upon 
percussion. Some mucous rale maybe audible in the upper portion 
of the trachea, owing to the accumulation of fluid in consequence of 
irritation. When the foreign body is moveable, — as a button, 
plumb-stone, &c, would be, — its motion up and down the trachea 
will be occasionally heard, as well as a valve-like sound produced 
by its being driven in expiration against the rima glottidis. There 
may also be perceived, at times, a temporary interruption to respira- 
tion in one lung, when the body happens to be impacted in the cor- 
responding bronchus, — the respiratory sound again returning when 
the obstruction has been removed by a violent expiration. It is 
said that the foreign body is most likely to pass into the right bron- 
chus, and that hence it is in the right lung we shall most frequently 
observe the obstruction of respiration.* 

The treatment indicated in these cases is unquestionably broncho- 
tomy, which, if the body be in the larynx, or loose in the trachea, 
may be looked upon as affording a fair prospect of success. The 
subject, however, must be gravely considered, before resorting to so 
formidable an operation ; and we must carefully collate the physical 
signs, with the history, both of the accident and of the previous state 
of the child's health, before we decide. The diseases, likely to pro- 
duce error, sometimes invade very suddenly ; but there is generally 

* We can never be too careful in investigating the history of sudden laryngeal 
affections : one among several instances in point, which came within our own ob- 
servation, it may, perhaps, be well to mention briefly: a child of three or four 
years old was suddenly seized with symptoms of croup, and actively treated ac- 
cordingly, for some days, when, as it was not becoming better, our opinion was 
sought for. It then appeared, upon close examination, that about the time of the 
first seizure the child had been playing in the kitchen, whilst the servants were 
dining upon herrings. The discovery of this circumstance led to the diagnosis of 
the real nature of the case: bronchotomy was recommended, and after considerable 
delay performed ; but too late to save the patient. After death, however, a herring- 
bone was found sticking in the ventricle of the larynx. See also a case by Dr. 
Evanson, in the 5th vol. Dub. Med. Journal. 



SPASM OF THE GLOTTIS. 265 

some appearance of illness previously, and their invasion is usually- 
accompanied with signs of general fever and disturbance of the sys- 
tem, which are wanting immediately after an accident. 

Foreign bodies, (as pieces of meat,) stopping in the fauces, and 
pressing upon the epiglottis, may produce all the distressing symp- 
toms occasioned at the first passing of any substance into the larynx, 
and may occasion sudden suffocation. In this case, relief may be 
given by passing in the finger and removing the obstruction, or by 
pushing it down the oesophagus by a probang ; but frequently, the 
body is beyond the reach of the finger, and the emergency' is so 
great as to admit of no delay, so that the only resource, and means 
of saving the patient, is the instant performance of bronchotomy. 
The nature of the operation, and other considerations belonging to it, 
fall within the limits of general surgery. 

VIII. SPASM OF THE GLOTTIS. 

A good deal of confusion appears to exist among medical writers, 
with regard to the application of this term, — partly owing to its 
being now applied to a disease which was formerly described under 
sundry names ; and partly to its being made to include, in common 
parlance, affections which perhaps have nothing in common, except 
the occasional occurrence of very sudden death. The disease 
described by Sir Henry Marsh as " spasm of the glottis,"* appears 
to be identical with — "the acute asthma of Millar," "Die krampf- 
hafte Engbriistigkeit of the Germans," " the inward fits" of Under- 
wood, " the peculiar species of convulsion" of Dr. John Clarke, "the 
cerebral croup" of Mr. Pretty," the laryngismus stridulus" of Good, 
and " the thymic asthma" of Dr. Kopp, and other late German 
writers. By others it has been confounded with the early stage of 
croup, or that mild threatening of the disease which occasionally 
occurs in irritable children, and has thence been denominated " spas- 
modic croup." In common parlance the term has been made the 
asylum ignorantix in all cases of sudden and unaccountable death 
occurring among children. 

A striking picture of the disease, as we understand it, is given in 
the able paper of Sir Henry Marsh, already cited. It occurs during 
the first two or three years of life, and appears to be frequently con- 
nected with dentition, and a deranged state of the digestive system, 
or of the general health, produced by impure air, fever, unsuitable 
nourishment, &c. At the commencement, the child, without perhaps 
showing any previous indications of illness, will be observed to 
awake suddenly from sleep, as if alarmed ; to struggle for breath, 
exhibiting all the signs of obstructed respiration, and, after repeated 
efforts, to recover with a long and sonorous inspiration, like that in 
hooping cough. Subsequently, the paroxysm may occur when the 
child is awake, especially if it be frightened or vexed. During the 
fit, the face often becomes swollen and purplish. After some time, 

* Dublin Hospital Reports, vol. v. 
23 



266 DISEASES OF THE RESPIRATORY ORGANS. 

as the disease advances, the hands and feet become slightly swelled, 
and the fingers and toes rigid, the thumb being frequently drawn 
into the palm of the clenched hand. We have observed the spasm 
to affect the extensor muscles, and to produce a permanent spread- 
ing and extension of the fingers, which, so far as our experience 
goes, appears to betoken less serious lesion of the nervous system 
than the opposite condition. As the disease advances, the health 
becomes considerably deranged, the bowels are out of order, stools 
green and slimy or curdy, child pale and unhealthy-looking. If 
neglected, general and fatal convulsions may supervene. The patho- 
gnomonic of the disease, according to Dr. Cheyne,* is crowing 
inspiration, with purple complexion, not followed by cough. We 
have noticed cases in which the crowing inspiration had a consider- 
able degree of permanency, and was not confined merely to the 
period of occurrence of the fit. The duration of the disease is very 
various : the child may be cut off suddenly in a paroxysm, by suffo- 
cation, or it may have attacks at intervals for several months, and yet 
recover. 

The pathology of spasm of the glottis is still very obscure. Sir 
Henry Marsh considers it to be primarily a spasmodic affection of 
the muscles of the glottis, and that it is only when the disease 
increases in severity, and when general convulsions arise, that the 
brain, or its membranes, become the seat of disease. He suggests 
that the primary lesion may exist at the origin of the pneumogastric 
nerve. He found the disease usually to occur in children of a stru- 
mous diathesis, and frequently, though not universally, to be com- 
plicated with painful dentition. Clarke and Cheyne conceived the 
seat of the disease to be in the brain. Kopp refers its cause to hy- 
pertrophy of the thymus gland, occasioning pressure upon the heart, 
lungs, and great vessels. More recently, Dr. Hugh Ley has pub- 
lished a lengthy essay upon spasm of the glottis, or laryngismus stri- 
dulus, as he terms it, in which he refers its cause to enlargement of 
the bronchial, or deep cervical lymphatic glands, producing pressure 
upon the recurrent nerves, and consequent paralysis of the muscles 
supplied by them. Without going into a consideration of these va- 
rious theories, it will be sufficient to say, that the affection is too 
constantly curable, and too frequently yields to a removal of specific 
irritations, as from dentition, deranged bowels, or indigestible aliment, 
to admit of its being referred to a cause decidedly organic. That 
enlargements of the bronchial, cervical and thymus glands are occa- 
sionally met with, as complications, we have no doubt, but when 
we recollect that the subjects of the complaint are usually of a deli- 
cate and strumous habit, such appearances are not to be looked upon 
as of much importance in relation to its special pathology. These 
remarks equally apply to other hypotheses having for their basis 
organic lesions ; and, therefore, we are inclined to adopt Sir Henry 
Marsh's view, and consider spasm of the glottis as essentially a spas- 
modic affection, but one liable to many organic complications, both 

* Treatise on Hydrocephalus. 



SUDDEN DEATH. 



267 



accidental, and consequent upon the continuance of irritation which 
it occasions in the system. 

The treatment of spasm of the glottis recommended by writers 
varies much, according to their views of its pathology. Our expe- 
rience of the frequent complications of the disease with difficult 
dentition, derangements of the digestive system, and with marks of 
a scrofulous diathesis, as well as its occasional dependence upon ex- 
posure to impure air, (the spasms, in a case of Sir Henry Marsh's, 
recurring whenever the patient was brought back to a newly-painted 
house,) have hitherto induced us to adopt the following plan : 

We would endeavour by all suitable means in our power to re- 
move complications, and restore the general health. When the 
bowels are deranged, alterative aperients should be used. If we 
observe teeth approaching the surface, the gums over them should 
be divided. If the child be suckling, all artificial food should be in- 
terdicted, a fresh and healthy nurse should be provided, and removal 
into pure air effected. When there is no manifest complication, small 
doses of sulphate of quinine or iodine may be given as tonics. Sir 
Henry Marsh found much advantage in the employment of the 
tinctura fuliginis of the old pharmacopoeias. All causes of excite- 
ment or irritation should be avoided; and during the fit, the child 
should be held up, and exposed to a draught of cool air. Every 
indication of an approaching affection of the head should be jealously 
watched, and treated according to circumstances.* 

Those who refer the disease to a hypertrophied condition of the 
thymus gland, advise a different mode of treatment, directed towards 
the lessening of congestion in that organ, viz., " a very low diet; 
abundant and often repeated local bleedings ; issues on the chest ; 
frequent energetic purgatives ; with a choice of mercurials, antimo- 
nials, cicuta, digitalis, animal charcoal, and iodine."? 

If we are justified, and we think we are, (at least in the absence 
of more certain knowledge,) in adopting Dr. Gooch's principle, of 
viewing the effects of remedies as tests for determining the differences 
of morbid conditions, our own experience tells us that the alterative 
and tonic plan we have recommended is the proper one ; and that 
the disease ive have described will always be aggravated by treating 
it, in the first instance, as an inflammatory or congestive affection. 
If, in its progress, it should be complicated with congestion within 
the head, depletion may become necessary, according to the indica- 
tions which will be considered when we are treating of head affec- 
tions ; but even then, the cachectic character of the primary disease 
must not be forgotten. 



We have stated that death sometimes takes place in children with 
unaccountable suddenness, and that such cases are usually referred to 
Spasm of the Glottis. For any thing we know to the contrary, at 

* See chapter on Affections of the Head, 
f Dublin Medical Journal, vol. ix. p. 521. 



268 



DISEASES OF THE RESPIRATORY ORGANS. 



present, it may be that the term is rightly applied ; but we wish to 
point out that the disease which we have been just describing, under 
the title of Spasm of the Glottis, has distinct characters and symp- 
toms, which mark it as different from the class of cases to which we 
are now alluding. We shall briefly state the particulars of the last 
instance of the kind which has fallen within our notice as the simplest 
mode of illustrating our views. 

A child of eight or nine months old was apparently recovering 
well from hooping cough ; its bowels were not materially deranged, 
it sucked well, and the cough was becoming less frequent and severe. 
The only remarkable circumstance was, that alarm was two or three 
times excited among its attendants, by the sudden occurrence of an 
unusual agitation in its breathing ; which, however, was so transient 
that no very clear account of its nature could be obtained. On the 
day of its death, it appeared lively, and better than usual ; but 
towards evening, while lying on its mother's lap, without cough, 
convulsion, or struggle of any kind, it suddenly expired. A careful 
examination was made of all the cavities, about eighteen hours after 
death, but without discovering any morbid appearance whatsoever. 
There was here no crowing inspiration, purple complexion, or other 
mark of obstructed respiration, or suffocation, which are so many 
pathognomonics of the disease we first described. 

We know of many occurrences similar to that just narrated. Pro- 
fessor Montgomery has lately given an account of some which fell 
under his notice.* He relates two in which there was some enlarge- 
ment of the thymus gland, and refers the fatal result to the pressure 
of that organ upon the trachea and great vessels and nerves. That 
this is not the constant cause of the event (we can scarcely call it a 
disease), we are perfectly certain ; for, in the foregoing case, the thymus 
gland was in a normal condition. It is probable, however, that 
there may be more than one occasional cause, and every observation 
upon the subject is interesting. 

As to the treatment, we have little to offer — the child is generally 
dead before we hear of its being ill ; but if our attention be directed 
to any unaccountable agitation in the breathing of an infant, we 
would be disposed to treat it upon the plan, already recommended 
in this section, for improving the general health. If there be any ap- 
pearance of enlargement or fulness in the region of the thymus gland, 
and that the condition of the child warrants us in supposing this to be 
of an inflammatory or congestive nature, a leech may be applied over 
the sternum, and subsequently some slightly irritating liniment 
rubbed upon the part. If we have reason to suppose the enlarge- 
ment to be scrofulous, the internal use of iodine will probably be of 
service. If we happened to be with a child at the moment of seizure, 
the performance of tracheotomy would undoubtedly be warrantable. 

IX. HOOPING COUGH (PERTUSSIS). 

This affection being one of those which regularly occur but once 
* Dublin Medical Journal, vol. ix. 



HOOPING COUGH. 269 

in the same individual, and that generally at an early period of life, 
it must be considered as a disease of childhood, although the memory 
of every practitioner will furnish him with instances of its invasion 
of even elderly subjects. 

The common notion is, that hooping cough is infectious, and that 
it is always propagated by infection ; but this has been doubted by 
many French and German writers, as Billard, Gardien, Wendt, Stoil, 
&c, who consider it as rather of an epidemic nature. This, like other 
questions of the kind, it is next to impossible to determine, as we have 
absolutely no means of distinguishing between an epidemic and conta- 
gious propagation of disease. It is quite certain, however, that hooping 
cough prevails most at particular seasons of the year, viz., at the 
close of winter and commencement of spring; and thus, whether or 
not it be spread, in individual instances, by contagion, it manifestly 
possesses epidemic characters. Girtanner* has advanced the notion, 
that the disease owes its origin to a specific miasm, analogous to that 
of marshes ; but for this opinion, we may at least say, that there is no 
foundation of fact. 

Symptoms. — Hooping cough commences, like an ordinary catarrh, 
with feverishness, thirst, coryza, tenderness of the eyes, and a fre- 
quent, dry cough. These conditions, which include no diagnostic 
marks of the disease, constitute the stage of incubation, and usually 
continue from four or five to ten days, although in some instances 
this stage is but little marked. At the end of the period of incuba- 
tion, the cough changes its character, and assumes the peculiar con- 
vulsive form which belongs to the disease. It occurs in paroxysms, 
or kinks, at intervals varying from half an hour to three or four hours, 
and is accompanied by long and noisy inspirations, with a crowing 
and whooping sound. This is pathognomonic of the disease, and has 
given it a name in most languages.! In some varieties, however, as 
when the patient is an adult, or a very young infant, the whoop 
may not be distinctly marked. 

During the paroxysm, the patient usually shows all the signs of 
impending suffocation — the face and neck become red, swelled, and 
often livid ; the vessels of the head are full, and a tensive pain is 
experienced in the forehead ; the eyes water, and appear as if start- 
ing from their sockets ; the pulse becomes quick ; the patient is 
greatly agitated, and lays hold of any fixed object which may be 
within reach. After this state has continued for a few minutes (more 
or less), the contents of the stomach are generally discharged, 
together with a large quantity of mucus, whereupon the coughing 
ceases, and the patient gradually recovers tranquillity. In severe 
cases, discharges of blood may take place, during the paroxysms, 
from the nose, eyes, lungs, or stomach, and even, (it is said,) from 

* Christoph. Girtanner Uber die Krankheiten der Kinder. Berlin, 1794. 

f In the old English works it is called Kink^ough ; by the Scotch, Kink-hoast ; 
by the French, Cuqueluche (explained by Billard to signify a congh coming from a 
person whose head is covered with a hood) ; by the Germans, Slick-huslen, Keich- 
/tuslen, and in some parts, Esels-husten , the whoop being likened to the braying of 
an ass. 

23* 



270 DISEASES OF THE RESPIRATORY ORGANS. 

the ears. Involuntary discharges may also occur from the bladder 
and bowels. Occasionally the patient falls down in a faint, from the 
extreme violence of the fit. The paroxysm returns with some degree 
of periodicity ; but it is often brought on irregularly by a full meal, 
exposure to cold, or any excitement. 

When the second stage has fairly set in, the symptoms of catarrh, 
in favourable cases, abate, and the fever is often very slight, — the 
patient being lively, and inclined to eat, during the intervals. The 
skin, however, is usually somewhat hotter than natural, and the child 
pale, and obviously out of order. The second stage of pertussis 
appears to have a definite duration — in favourable cases, about 
three or four weeks — at the end of which it begins naturally to 
decline in severity, the secretion of mucus becoming more abundant, 
the cough looser, the paroxysms less violent and fatiguing, and the 
intervals longer, until at length, in two or three months from the 
first onset, the disease ceases altogether. The duration of the second 
stage, however, though it probably cannot be very much shortened 
by art, admits of being considerably extended by many accidental 
circumstances, as taking of cold, &c. ; and relapses of the convulsive 
cough are liable to occur, even after the patient has appeared for 
several days to be altogether free from the disease. 

Pathology. — Morbid anatomy has thrown no light upon the 
proximate cause of hooping cough ; and accordingly, as is always 
the case in the absence of exact knowledge, the subject has been 
deluged with a flood of hypotheses, — none of which, however, can 
claim to be more than plausible guesses : many are merely a re- 
stating of ignorance, in obscure, and therefore (according to the 
notion of some) scientific words. The fact is, the simple disease is 
probably never fatal ; and therefore, any appearances which we 
may meet with in the dead body are the results of complication — 
e. g., marks of inflammation in the lungs or brain. 

We shall now merely allude to some of the opinions in question. 
By Cullen, hooping cough was placed among the neuroses, and con- 
sidered as a specific irritation of the nervous system. Hufeland, Pal- 
damus, Jahn, Breschet, and others, supposed the particular lesion to 
be in the phrenic and pneumogastric nerves. Lobenstein-Lobel 
believed it to exist, primarily in the diaphragm, and that the irrita- 
tion was subsequently communicated to the nerves just mentioned.* 
Webster locates the disease in the brain itself. Watt, Marcus, Albers, 
and Guersent, look upon it as a simple bronchitis ; Desruelles, as a 
bronchitis followed by cerebral irritation — a broncho-cephalite, as 
he terms it. To a similar view, Dr. Johnson also appears to incline.t 
Dr. Butter designates the bowels as the seat of the primary lesion 
Autenrieth believes the origo mali to be a determination of morbid 
matter towards the bronchi, and hopes to divert it away by exciting 
morbid pustules upon the skin. Holzhausen and Clarus found, in 
the body of a boy who had died of hooping cough,the phrenic nerves 

* See Wend I, op. cit. 

t See his able article, "Hooping Cough," Cyclopaedia of Practical Medicine. 



HOOPDsG COUGH. 271 

loose in texture, and somewhat swollen ; the trunks of the vagi like- 
wise looser, thicker, and broader than natural ; the great sympa- 
thetic and splanchnics, especially the latter, of a firmer consistence 
than usual ; and the cceliac plexus firmer and somewhat elevated.* 
But, in point of fact, there is no part of the body which has not been 
found diseased after hooping cough, and assigned as its seat by those 
who argue post hoc, ergo propter hoc ; as an example of which we 
may mention, that Girtanner lays some stress upon his having 
found the parts of generation in a morbid condition upon these 
occasions. 

We shall not add to this tangled web of opinions by any specula- 
tion of our own, but freely confess our entire ignorance as to the 
intimate nature of the affection. All we know is, that the symptoms 
in the first stage show the bronchial mucous membrane to be in a 
state of irritation, if not inflammation ; and that in the second they 
assume a distinctly spasmodic character. 

Diagnosis. — The diagnostics of hooping cough are, the whoop 
and the paroxysmal character of the cough, by which, when it is 
uncomplicated, it may be readily distinguished from all other 
diseases. 

Prognosis. — In simple pertussis, occurring in a healthy child, the 
prognosis is favourable ; but should always be modified by a due 
regard to the liability to occurrence of dangerous complications, 
which is so great as to cause the deaths under the head of hooping 
cough to constitute a formidable item in bills of mortality. Those 
complications are most likely to occur, and to be dangerous, in very 
young children, in those just weaned, or suffering from dentition or 
other causes of delicate health ; and in those of a naturally unsound 
constitution. All these collateral circumstances should therefore 
be taken into account, in giving our prognosis, and the danger of 
the sudden supervention of another disease distinctly adverted to. 

Treatment. — The treatment in simple, uncomplicated hooping 
cough, must be one rather of prevention than cure. Our chief ob- 
ject should be to avert inflammations or congestions of important 
viscera, as the lungs, brain, or digestive apparatus. During the 
stage of irritation of the bronchial membrane, we must keep down 
the general and local fever, by quietude, low diet, and such eva- 
cuants as the symptoms may demand. A mild emetic of ipecacuan 
will almost always be serviceable, and will generally accomplish 
another indication, by freeing the bowels.f Should it not do this, 

* Wendt, op. cit. 

f The prescriptions of Fothergill and Pearson will, either of them, answer well 
under the above mentioned circumstances. The former is — 

R. Pulv. e. Chel. Cancr. ^ss. 
Tartar. Emet. gr. ij. 
Accurate misceantur — gr. i. — gr. ij. indies. 
The latter- 
ly. TincturEe Opii, guttam. 
Vini Ipecacuan. gtts. v. 
Carb. Sodae, gr. ij. 
Ft. Pulvis 4ta quaque hora sumendus. 



272 



DISEASES OF THE RESPIRATORY ORGANS. 



however, we may administer one of the aperients recommended in 
Chap. V. The child, during the first stage, should certainly be con- 
fined to its apartment, which should be well ventilated, but kept 
moderately warm ; and we should not be led to deviate from this 
rule by the popular notion, that change of air is good for the disease. 
The notion is quite true in the latter stages, when the cough is ob- 
viously spasmodic, and kept up more by habit, than by any actual 
irritation ; but it leads to very injurious consequences, when acted 
upon during the irritative period. The state of the lungs must be 
carefully watched throughout, and the first symptoms of an inflam- 
matory kind, met at once by bleeding and leeches. Should no un- 
toward circumstances, however, interfere, the first stage will pass on 
without a necessity arising from active treatment ; the bronchial 
irritation will gradually subside, and the cough assume the spasmo- 
dic character. 

It is at this period, when the fever has abated, and the appetite is 
beginning to return, with, at the same time, a complete freedom from 
wheezing, or other indication of pulmonary affection during the in- 
tervals, that we shall find change of air productive of benefit, and 
that we shall be enabled to employ any of those antispasmodic me- 
dicines which are in general repute. We must, however, still ob- 
serve great caution. Fine weather should be selected for bringing 
the child into the open air, and it should always be well clothed and 
protected from the cold. 

Something perhaps may be done in breaking the habit of the dis- 
ease, by tonics or antispasmodics, and a vast variety of such have 
been recommended — too great a variety, indeed, to allow of our 
putting much faith in any single specimen. Cantharides, with bark, 
has been much recommended, and, when used in suitable cases, will 
sometimes be found serviceable.* We have also found belladonna 
useful, in doses of an eighth of a grain, three or four times daily. 
Oxide of zinc was recommended by Guersent, in doses of a grain, 
every hour; cicuta, by Butter and Stork; extract of tobacco, by 
Stoll, Hufeland, and Thilenius ; wild rosemary, by Linnaeus and 
Wahlborn ; arsenical solution, in doses of a drop daily, by Dr. Fer- 
riar, &c.,&c. ; but it is needless to encumber our pages with an enu- 
meration of more specifics, as their very multiplicity affords a strong 
presumption in favour of their inefficacy. Autenrieth, arguing upon 
his theory of the nature of the disease, — viz., that it was a deter- 

* The following formula was much employed by the late Dr. Beatty of Dublin : 

B. Tinct. Cinchon. Comp. Jv. 

Cantharid. 

1 Opii Camphor, aa. ^ss. M. 

3ss — 3i. ex cyatho decocti hordei ter indies. 

Burton, the original proposer of cantharides in hooping cough, trave it in powder, as 
follows : 

R. Cantharid. 

Camphor, aa. ^i. 
Extract. Cinchon. 5»ij. 
Tere simul — gr. viij. 3tia vel 4ta quaque hora. 



HOOPING COUGH. 2 7 « 

mination of peccant matter upon the lungs, has advised the deriva- 
tion of this matter toward the surface of the body, by the employ- 
ment of tartar emetic ointment, so as to bring out a crop of pustules ; 
but this is merely a clumsy and unmanageable mode of counter- 
irritation, and is not suitable in child's medicine. 

After all that has been said and written respecting specifics for 
hooping cough, perhaps as good a medicine as any, during the de- 
cline of the complaint, will be one of the expectorant mixtures pre- 
scribed in Chapter V.* 

During the whole progress of a case of hooping cough, we must 
be alertly upon the watch for the first signs of local inflammations. 
The most common of these is bronchitis, the symptoms and treatment 
of which are detailed under their proper head. Here we have only 
to say that when it does supervene or threaten, it must be met by 
active depletion and loss of blood, general or local, according to the 
symptoms; and from this practice we are not to be deterred by any 
preconceived ideas as to the nervous or spasmodic nature of the dis- 
ease. We cannot too often repeat, that the great danger of pertussis 
arises from the likelihood of the supervention of local inflammation re- 
quiring active and prompt treatment. 

Other local affections, very apt to complicate hooping cough, are 
hydrocephalus, or convulsions, and the probability of their occurrence 
should never be lost sight of. The symptoms and treatment of these 
affections will be adverted to in their proper place; but we may 
mention that clenching of the hands, the thumbs being turned 
into the palms, drowsiness, screaming out during sleep, and, as Dr. 
Johnson justly remarks, "greater irritability of the stomach than we 
can account for, or than is natural during hooping cough," are marks 
which always call for our most strenuous exertions for the aversion 
of head affections. 

Remittent fever, and severe derangement of the bowels, is a com- 
mon complication of the second stage of pertussis, and is not unfre- 
quently dangerous, or even fatal. The fever, and the increase of the 
cough and hurry of the respiration, which commonly attend upon it, 
may often lead us to mistake this complication for bronchial inflam- 
mation. The diagnosis must be derived from the absence of direct 
signs (as the auscultatory) of pulmonary disease ; the occurrence of 
distinct remissions ; the condition of the mucous membrane, &c, — 
all of which have been dwelt upon, when treating of remittent fever. 
The liability to the occurrence of derangement of the bowels, should 
warn us against the indiscriminate and wanton use of purgative or 
other irritaUng medicines, in the treatment of hooping cough. Many 
simple cases of the affection have been, no doubt, hampered with 
dangerous complications, by this unhappy practice. For the manage- 
ment of derangement of the bowels and remittent fever, we must 
refer to the chapter devoted to those subjects. 

When hooping cough happens to attack a child while undergoing 
the process of dentition, very special attention to the case is demanded. 

* Nos. 15, 17, 19. 



274 DISEASES OF THE CEREBRAL SYSTEM. 

At this period, both the abdomen and head are peculiarly likely to 
be engaged; and we shall best prevent these occurrences by carefully 
watching the state of the gums, and treating them according to the 
principles laid down in the chapter upon Dentition. 



CHAPTER X. 

DISEASES OF THE CEREBRAL SYSTEM. 
I. FUNCTIONAL DISEASES. 

The peculiarities of structure to be observed in the nervous system 
of the infant have been already pointed out, and sufficiently account 
for the facility with which disturbance of that system takes place 
during childhood. 

The great susceptibility to impressions, in consequence of the large 
mass of brain* and the readiness with which the balance of the cir- 
culation is deranged, in consequence of its great vascularity, fre- 
quently give rise to a state of morbid irritation or congestion, which, 
though not constituting organic disease, may soon lead thereto. We 
shall consider separately the disorders of the cerebral system con- 
nected with inflammatory action, and those existing independently 
of inflammation. The latter may give rise to very serious symp- 
toms, or even lead to a very fatal result, as we witness in certain 
cases of irritation, congestion, convulsions, &c, &c, of which we now 
proceed to treat. 

We recognise the symptoms of morbid irritation, or erethysm of 
the brain, (as Dr. Whitlock Nicol calls it,) when we perceive an 
unusual degree of acuteness in the sensations of a child ; while it is 
fretful, unquiet, or affected with wakefulness. Noise and light are 
disliked, the eye being as over-sensitive as the ear, and often winking 
before a bright light ; or the lids are spasmodically closed. The hand 
is occasionally clenched, or the thumb thrown across the palm; and 
frequently, sneezing is present. The temperature of the body, and 
state of the pulse, are both natural, though occasionally the skin may 
be hot or the pulse raised ; but the signs of determination of blood 
to the head are absent. If the spinal marrow be engaged in the irri- 
tation, the head is thrown back; or there may be some degree of 
opisthotonos present, with occasional twitchings or convulsive move- 
ments of the limbs, and great sensitiveness of the whole surface. 

Wakefulness is a very prominent character of nervous irritation 

* M. Billard, however, has noticed that affections of the spinal cord are more 
frequent in the young infant than those of the brain ; and M. Ollivier states that 
the symptoms of the former are much better marked than those of the latter — the 
functions of the brain being as yet so little exercised, in consequence of its imper- 
fect structure, that their disturbance scarcely attracts notice. 



FUNCTIONAL DISORDER. 2 75 

ill the child, and should always arrest attention. When obstinate, it 
is a dangerous sign, often preceding inflammation of the brain, par- 
ticularly in children predisposed to hydrocephalus, or who are labour- 
ing under fevers, as measles, scarlatina, &c, &c. In the latter disease, 
especially, this symptom is often as distressing as it is dangerous. 

Somnolency is an occasional symptom of sympathy of the brain, 
with an overloaded state of the stomach, or costive condition of the 
bowels ; and a tendency to drowsiness, or even stupor, will often 
vanish on the exhibition of a brisk cathartic. The presence of worms 
may occasionally give rise to similar symptoms. 

The common cause of morbid irritation in the brain are, debility, 
or the excitement produced by stimulants improperly given ; a 
deranged state of the bowels, the injurious effects of low, damp situa- 
tions, and ill-ventilated apartments; or moral impressions, such as 
fear, anger, &c. We have already pointed out the relation between 
this state and the process of dentition (p. 162). In all these cases, 
irritation is very prone to pass into inflammation, and thus hydro- 
cephalus may be established. 

Treatment. — Our first effort must be to ascertain and remove 
the cause of this affection ; our next, to apply such means as are cal- 
culated directly to, allay the morbid irritability of the nervous system. 
The state of the bowels primarily demands attention, as also the cha- 
racter of the secretions. Care must be taken to regulate the diet, 
which should be nutritious without being stimulating ; and removal 
to a healthful situation, if necessary, or, at all events, free exposure 
in the opon air (while exposure to noise or a bright light are avoided), 
is essential in restoring the balance of the nervous system. Cold to 
the head (which should be daily sponged with vinegar and cold 
water), while the feet are occasionally immersed in warm water, or 
the warm bath employed, are measures directly calculated to allay 
the irritable condition of the brain, and in particular to restore 
sleep, when wakefulness is present. In some alarming cases of this 
description, we have seen tranquillity quickly restored, and sleep in- 
duced, by the use of the warm bath, while cold was, at the same 
time, assiduously applied to the head, and the application continued 
until the child appeared to grow faint. In this form of cerebral 
affection, the judicious use of narcotics is of signal service ; but they 
need not be resorted to until the other means mentioned have been 
tried. In acute cases of morbid irritation, where the symptoms ap- 
proach those of inflammation, our treatment must be more active — 
leeches, cold to the head, active purgatives, or counter-irritation, 
being employed ; and such should always precede the use of narcotics 
in these cases. 

Co?igestion is not an unfrequent condition of the brain during in- 
fancy, and may be present immediately after birth ; but the symp- 
toms are very often obscure. We consider that congestion is present, 
however, when a child is stupid and heavy ; the head looking full, 
and being, perhaps, hotter than usual ; with the veins distended, and 
dark-coloured, or the countenance livid ; and the pulse slow, or it 
may be irregular. The pupils are usually dilated, the eyes looking 



276 DISEASES OF THE CEREBRAL SYSTEM. 

vacant, or they are with difficulty fixed on the same object. The 
state of the fontanelles (as we remarked in our Chapter on Diagnosis), 
affords an important source of information ; and this, though seldom 
set forth in books, is always to be looked to by the practical physician. 
A permanently elevated and convex condition of the fontanelle, 
joined to the above symptoms, leaves no doubt of the existence of 
congestion of the brain. 

Cerebral congestion is liable to occur at the commencement or 
towards the conclusion of the exanthems in the child, and is always 
to be regarded as a serious symptom. Congestion may lead to inflam- 
mation, but is less likely to do so than irritation ; more particularly 
in young infants, in whom Billard remarks that inflammation is 
much less liable to follow congestion of the brain, than when either 
the stomach or lungs are the seat of this affection. 

Congestion more frequently leads to effusion, and in some cases 
this occurs very rapidly. We have seen a child suddenly seized with 
an attack of convulsions, accompanied by signs of congestion, and 
dying comatose in less than twenty-four hours. Venous congestion 
of the pia mater, with copious effusion into the ventricles, were the 
appearances found after death. Mere irritation seems, however, 
capable of producing similar results — effusion being found, but with 
little signs of congestion ; and inflammatory action at times runs this 
course so rapidly, that doubts must be entertained as to whether such 
had previously existed. Golis speaks of attacks of this description, 
which he calls " the water stroke," — effusion and death taking place 
in a few hours. He looks upon this as a variety of hydrocephalus, 
the inflammation and effusion being almost coincident ; and hence 
he designates it as hyper-acute. This form of the complaint may be 
idiopathic ; but is generally brought on by the sudden suppression 
of some accustomed discharge, or the repulsion of one of the exanthe- 
mata. 

Effusion. — No signs, exclusively indicative of effusion, appear to 
exist, as is now acknowledged ; for those usually enumerated may 
be present without effusion having taken place, while effusion is 
occasionally found where no such signs are present. When, how- 
ever, the head gradually enlarges, with the fontanelles full, we may 
consider that effusion is the cause ; or in more rapid cases, insensi- 
bility, with muscular relaxation, debility or paralysis, generally indi- 
cates the presence of effusion. 

We have seen cases in which the head enlarged during the presence 
of febrile symptoms, and those of cerebral excitement, but without 
dilated pupil, coma, or paralysis ; and which we were inclined to 
look upon as cases of hypertrophy of the brain, that again subsided 
under the use of antiphlogistic measures. 

Treatment. — This will consist, in cases of congestion, in the 
assiduous application of cold to the head, while heat is at the same 
time applied to the extremities, or the general warm bath employed. 
The bowels should be emptied out by purgative enemata ; and occa- 
sionally leeches may be required ; but they should be used with 
caution, and are better applied to one of the extremities, or the back 



FUNCTIONAL DISEASES. 



277 



of the neck, than directly to the head. Sinapisms, or blisters, will 
be more frequently necessary, and they should be first used on the 
extremities ; but afterwards counter-irritation, applied directly to the 
head, is most serviceable. 

Hydrencephaloid Disease. — The attention of the profession has 
been directed, by Dr. Marshall Hall,* to a train of symptoms occa- 
sionally met with in children, and similar to some that occur in con- 
gestion or hydrocephalus ; but which differ from these in certain 
respects, particularly in being induced by a state of exhaustion ; and 
which, therefore, require a plan of treatment opposite to that neces- 
sary for an inflammatory affection. Dr. Goocht has also treated of 
this subject ; and it has been alluded to by Dr. Abercrombie. The 
disease is called hydrencephaloid, to distinguish it from inflamma- 
tory hydrocephalus. It can hardly be looked upon as a disease, 
however, but rather as a condition of the system leading to symp- 
toms of oppression of the brain, unconnected with an inflammatory 
origin, but which may succeed to an inflammatory affection, when 
depletion, particularly bloodletting, has been carried too far. From 
such source, Dr. M. Hall saw it generally arise, and found it con- 
nected with congestion. Dr. Gooch saw it arise from a delicate 
state of constitution, independentlv of this source, and found the ven- 
tricles distended with fluid, but the vessels of the brain remarkably 
empty. 

The symptoms are, drowsiness, with occasional delirium; the 
pupils are dilated, the eyes being kept usually half-closed, and there ' 
may be squinting or blindness ; the pulse is feeble, but may be 
quick, slow, or irregular ; the surface is cool, particularly the face 
and extremities ; the breathing becomes hurried and unequal, and 
the child, if unassisted or mismanaged, dies comatose or convulsed. 

The treatment consists in supporting the strength by nourishing 
diet and stimulants, as beef-tea or arrow-root, and giving aromatic 
spirit of ammonia, or brandy, (from five to ten drops for a dose,) 
until reaction is established, when the use of stimulants is to be 
cautiously withdrawn. Should much restlessness be present, small 
doses of opium are to be given, or the warm bath employed. Purg- 
ing or vomiting, if present, is to be checked. 

In this disease, we must be careful to avoid putting cold to the 
head, or raising the child suddenly up, and keeping it in an erect 
posture. By attention to these particulars, childr^i may be saved, 
who are said to be dying from hydrocephalus, bi who must have 
irretrievably perished had antiphlogistic measures been employed. 

The necessity for taking the entire condition of the patient into 
account, in affections of the head, and not merely looking to the 
cerebral symptoms, is admirably illustrated by these cases. 

Convulsions may be induced by any of the morbid conditions of 
the nervous system of which we have spoken, or may be merely 
sympathetic. Convulsions are not, generally speaking, so dangerous 

* See Dr. M. Hall on a Morbid Affection of Infancy, &c. 
| See Gooch on Diseases of Women, p. 355. 
24 



278 DISEASES OF THE CEREBRAL DISEASE. 

an affection as might be at first imagined ; nor is the degree of danger 
directly proportionate to the violence of the attack, as slight convul- 
sive movements may indicate a more serious affection than violent 
convulsions. When very violent or often repeated, however, a fatal 
termination, or an incurable state of paralysis, may result.* 

Very young infants are liable to a spasmodic affection, to which 
nurses give the name of inward Jits. The infant smiles often in its 
sleep, and rolls about its eyes ; the mouth being occasionally drawn 
down, with slight twitchings of the lips, and at times there is some 
surrounding blueness. This state, which can hardly be called one of 
convulsion, is usually induced by over-distension of the stomach or 
bowels, from the presence of flatulency or undigested food ; and will 
be relieved on removing its cause by the exhibition of a mild aperient, 
or a few drops of turpentine, or spirit of ammonia, in an aromatic 
water. 

Symptoms. — During a severe attack of convulsions, all the 
voluntary, and many of the involuntary muscles, are spasmodically 
contracted. There is starting of the eyes, or distortion of the eye- 
balls ; the tongue is protruded, and there is foaming at the mouth. 
The head and face are often red at the commencement of the attack, 
but become purplish towards the conclusion, as likewise at times 
does the whole body. The respiration is obstructed or laborious ; 
and the hands are, in general, firmly clenched, as well as the limbs 
being in violent motion. The attack may be momentary, or continue 
but for a short time ; or the convulsions may be frequently repeated, 
and last for many days. As the paroxysm subsides, the convulsive 
movements become less frequent, and less violent ; the muscular 
contractions relax ; the natural appearance returns, and the child 
becomes able to cry, having taken a full and deep inspiration. A 
calm sleep often follows, attended by a free perspiration ; and the 
child awakes refreshed, and apparently quite recovered. 

The convulsive attack may be much milder than that just described. 
Only one limb, or one side of the body, may be convulsed ; and this 
may alternate occasionally, or several times in succession, with a 
similar condition of the opposite side. The face alone may be 
affected, or only slight twitchings of this part, or of the limbs, be 
present, with some blueness about the mouth, and perhaps distortion 
of one of the eyes. Neither fever nor disturbance of the mental 
faculties necessarily attend an attack of convulsions ; but when they 
do, or the circulation is much accelerated previous to the attack, an 
inflammatory affection is to be apprehended. Convulsion attends 
on a directly opposite state, however, — one of depression or debility, 
— as has been described under the head of hydrencephaloid disease. 

Convulsions may come on suddenly, without any previous warn- 
ing, or there being any derangement in the child's health, to account 
for the attack. Generally they occur in children who are in delicate 
health, and hence their nervous system in a state of morbid irritability. 

* According to M. Billard's experience, the convulsive attacks of young infants 
arise most frequently from an affection of the spinal cord or its membranes. 



FUNCTIONAL DISEASES. 279 

Under these circumstances, very slight causes will occasionally induce 
an attack ; as any sudden fright, the irritation of teething, pain, flatu- 
lency, constipation, the ingestion of unwholesome food, the presence 
of worms, or the sudden suppression of an eruptive disease, or 
accustomed discharge. 

Some precursory signs, however, often attend ; and these, in 
general, indicate a highly irritable state of the nervous system. In 
addition to the characters already enumerated, as belonging to this 
state (see p. 274), we observe, in particular, when convulsions threaten, 
some unusual appearances about the eyes, which are frequently fixed, 
or in oscillatory motion, the pupils suddenly contracting or dilating ; 
or there may be want of consent between the pupils, — one being 
dilated, while the other is contracted ; or difficulty in fixing the eyes 
together on one object. The condition of the hands and feet specially 
deserves attention. There are frequent twitchings of the fingers or 
toes ; the hand is clenched, and the thumb pressed stiffly across the 
palm ; or the wrist is bent downwards, as well as the foot, and the 
toes drawn in. Sudden animation is often followed by langour, and 
the breathing is irregular ; in particular, a long and deep inspiration 
often follows short catchings of the breath. There is alternate flush- 
ing and paleness of the face ; or the countenance looks pinched up, 
and a peculiar blueness is observed about the mouth. 

Prognosis. — As delicate and irritable children are more easily 
thrown into convulsions than those that are robust ; so we must look 
upon convulsions as more dangerous in the latter, especially when 
connected with inflammatory diseases. The worst cases that we 
have seen, Occurred in such ; but in any instance, the attack may 
prove fatal, if violent, and hence our prognosis must be always 
guarded. As convulsions can never be looked upon as purely idio- 
pathic, much will depend on our being able to ascertain and remove 
then causes ; and this should form, the object of our treatment, not 
merely an attempt to palliate or control the convulsive motions. 

Treatment. — Having endeavoured to remove or mitigate any 
source of irritation, — as by freeing the bowels when loaded, dividing 
the gums if requisite, or using antiphlogistic measures to subdue 
inflammatory action when present, much does not require to be done 
for the convulsive attack itself, as this generally tends to pass away 
of its own accord. Attempts to stop the convulsions by opiates, 
stimulants, &c, will always do harm, unless where the symptoms 
clearly arise from irritation or exhaustion. The child's clothes 
should be always loosened, the head elevated, cold air admitted, and 
the face sprinkled with cold water. The application of cold to the 
head is the remedy of most general utility, and most effectual in 
abridging the paroxysm and preventing its return. The use of heat to 
the feet, or the warm bath, at the same time, is of signal service, adding 
much to the efficacy of the cold applications. The mode of applying 
cold now universally adopted in cases of convulsion, is by pouring 
a stream of water on the head, from a vessel held at a little distance 
over it, and continued until the attack subsides. Leeches are occa- 
sionally required, if much febrile excitement or oppression of brain 



230 DISEASES OF THE CEREBRAL SYSTEM. 

are present. It is often difficult to move the bowels in such cases ; 
but purgatives, which are in most instances requisite, will act more 
easily after leeching has been practised. Purgative enemata, with 
turpentine, often give speedy relief. When much restlessness or 
nervous irritation is present, small doses of Dover's powder are often 
of great service ; but in convulsive attacks attendant on inflammatory 
action, great injury may be done in attempting to control the con- 
vulsions by narcotics. Still more particular must we be to avoid the 
use of stimulants, sometimes employed as antispasmodics, but which 
always aggravate or renew the convulsions in such cases. It is 
when debility is the cause of convulsions (as in the hydrencephaloid 
disease), that stimulants, as ammonia, brandy, or turpentine, must 
be resorted to. After convulsions have once attacked a child, they 
are liable to recur ; and care must be taken to avoid every exciting 
cause, and all means must be employed to improve the general 
health and strength ; in delicate children, change of air, and tonic 
medicines, are essential. 

[Very violent attacks of convulsions not unfrequently result from 
the presence of irritating or indigestible substances in the stomach : 
in these cases we have found little benefit to result from the use of 
any of the usual remedies until the cause of irritation in the stomach 
is removed by an emetic ; upon the full operation of which we 
have, in repeated instances, known the convulsions to be imme- 
diately suspended. — C] 

II. INFLAMMATORY AFFECTIONS. 

The brain, or its membranes, may be attacked with acute inflam- 
mation in the child, as well as the adult ; but this form of inflamma- 
tion is comparatively rare in children, or occurs only in those that are 
robust and plethoric. The more common forms of cerebral inflam- 
mation to which the child is subject, present, in general, a low or 
insidious character ; they appear to partake much of the nature of 
scrofulous inflammation, as seen elsewhere, and indeed most fre- 
quently occur in strumous children. It is not easy to determine 
what the peculiarity is ; but we agree with Br. Cheyne, that hydro- 
cephalus consists, in many instances, of " a diseased action of a pecu- 
liar kind, but of what, we can as little explain, as we can the nature 
of scrofulous action." One peculiarity in this form of morbid action 
is, its tendency to throw out fluid, or cause effusion ; and hence the 
name hydrocephalus or dropsy of the brain. This effusion of water, 
however, is not essential to the symptoms which are usually looked 
upon as constituting a case of hydrocephalus : for all these may be 
present, without water being effused ; or water may be found, where 
the chief of these were wanting. The symptoms seem to depend 
truly on that morbid condition of the brain, or its membranes, which 
gives rise to the effusion ; but the latter is only an accidental , though 
frequent, consequence of this morbid action. Effusion may even be 
found where no inflammation had existed ; or be induced by debility, 



INFLAMMATORY AFFECTIONS. 



281 



or the exhaustion brought on by excessive evacuations. The more 
slow the disease is, and the less it partakes of the acute inflammatory 
character, the more certainly, in general, will water be effused, and 
the greater will be the quantity. The cause, then, why effusion of 
fluid is so much more common in the child than in the adult, ap- 
pears to be the greater liability to this peculiar form of inflammatory 
action, and the greater latitude that there is given to the effusion of 
fluid, in consequence of the expansile properties possessed in the 
young cranium. The substance of the brain may be the seat of mor- 
bid action, leading to ramollissement and effusion, with disease of 
the membranes ; or the softening of the brain may result from the 
disease going on in the membranes, when this is protracted and leads 
to effusion.* The arachnoid membrane is that usually affected ; and 
it has been remarked by Martinet, that the arachnoid at the base of 
the brain is more frequently the seat of inflammatory action in the 
child — that of the convex surface in adults. Each of these varieties 
is distinguished by particular symptoms. 

The connexion between hydrocephalus and strumous affections 
has been long remarked, and Dr. Gerhard, of Philadelphia, points 
out a peculiar form of the disease, which he denominates tubercular, 
and has accurately described in two valuable papers,' published in 
the 13th and 14th volumes of the American Journal of the Medical 
Sciences. M. Ruz has farther stated, that in several cases in which 
tubercles were found in the cerebrum or cerebellum, he detected 
small, white, semitransparent granulations in the arachnoid mem- 
brane, especially at the base of the brain ; and similar granules were 
discovered in other situations, as the peritoneum, pleura, &c, &c, 
while tubercles- were uniformly present in the lungs. 

The curability of hydrocephalus seems to depend much on the 
nature of the morbid action giving rise to the symptoms — the acute 
inflammatory form of the disease being amenable to active depletion ; 
while in the low, or strumous variety, depletion is ill borne, and 
recovery uncertain. That described as the tubercular appears to be. 
the most hopeless form of this species of the disease. 

As morbid anatomy has not yet enabled us perfectly to clear up this 
subject, or to determine with certainty, by the symptoms, the precise 
lesion of the brain present, we shall still treat of hydrocephalus under 
its ancient appellation, — not forgetting, however, that it is not a 
mere passive dropsy, as was formerly thought ; and recollecting that 
it is not always an acute inflammatory disease, as has been more 
recently taught. 

* Abercrombie seems to regard an inflammatory affection of the central portions 
of the brain, ending generally in softening of its substance, as the essential lesion 
in hydrocephalus, whether there be effusion or not. Lallemand pretends to dis- 
tinguish between the affection of the substance of the brain and that of the mem- 
branes ; but this can be attempted only in the early stages of the two affections — 
which may, however, exist together ; while the direct communication by blood- 
vessels is such, that an affection of either structure may, from the commencement, 
give rise to symptoms connected with the other. 
34* 



282 DISEASES OF THE CEREBRAL SYSTEM. 

Hydrocephalus may be acute or chronic; and its progress is 
usually marked by certain alterations in the condition of the patient 
and the symptoms, which have led to its division into stages or periods. 
These are often well marked ; but we must not always expect to 
find them distinctly formed. It has been attempted to connect the 
peculiarities of the symptoms in each stage, with the particular 
pathological condition supposed then to exist ; and the state of the 
nervous or vascular systems is that usually taken as the type of each 
period. Thus we have, first, the period of increased sensibility of 
Cheyne, with the quick pulse of Whytt ; or the period of inflamma- 
tion of Golis. Then we have the second stage, or that of diminished 
sensibility, according to Cheyne, with the slow, irregular pulse of 
Whytt ; and looked upon as the period of effusion by Golis. Again, 
we have the last stage, characterised by the pulse rising once more, 
and becoming rapid, but feeble ; when convulsions or palsy attend. 

Differences are also to be observed in the mode in which hydro- 
cephalus makes its attack : this is modified by the form in which the 
complaint presents itself, and the condition of the patient at the time. 
In healthy children, we sometimes see hydrocephalus set in with 
violence, — there being sudden fever, or severe convulsions, at the 
onset ; the disease presenting a highly inflammatory character. This 
form of attack, however, is that less frequently met with ; and hydro- 
cephalus most commonly commences in a gradual or obscure manner. 
The premonitory symptoms are not sufficiently peculiar to command 
attention : but generally the digestive organs are observed to be 
deranged in a particular manner, and the nervous system much dis- 
turbed ; and these conditions will not be found to yield to the use of 
purgatives, or other medicines, as readily as might be at first expected. 

During the progress of febrile disorders, or after the occurrence of 
one of the exanthemata, particularly scarlatina, hydrocephalus is 
liable to make its attack in a secondary form, — approaching insidi- 
ously during the progress of the complaint, or appearing suddenly on 
any rapid subsidence of the symptoms. During the progress, then, 
of any infantile fever, or protracted disease, as scrofulous affections, 
hooping cough, painful dentition, or disorders of the bowels, as be- 
fore observed, we should be on the watch for cerebral symptoms ^ 
and on any unusual irritability of the little patient, particularly an 
irritable state of the stomach, not otherwise to be accounted for, we 
should apprehend that the head was becoming engaged, and narrowly 
watch all the symptoms. In such cases, the symptoms of the early 
stage are often absent ; and convulsions or palsy, will be the first 
unequivocal sign of an affection of the head. 

Symptoms. — In the most acute, and therefore best marked form 
of hydrocephalus, the symptoms indicative of cerebral disease set in 
with severity after a short period of previous indisposition, which is 
very liable to be overlooked. The child is seized with severe pain 
in the head, which usually appears to be referred to the forehead or 
temples ; the head is hot, and face red ; the vessels are distended, 
and throbbing; there are frequent flushings; the .eye is unusually 



INFLAMMATORY AFFECTIONS. 283 

brilliant;* light is disagreeable, and noise distressing; the child 
starts on the slightest touch or sound ; and there is increased sensi- 
bility of the whole nervous system. 

The fever sets in violently and suddenly, the intermissions being 
very short and irregular ; the pulse is, at first, full and rapid ; the 
breathing is hurried or oppressed. Much derangement of the diges- 
tive organs is present, the bowels being obstinately costive, and the 
discharges very unnatural, when obtained, which it is, in general, 
very difficult to effect, even by the strongest purgatives. The urine 
is usually scanty, or suppressed, and may be white. The state of the 
stomach, in particular, is characteristic of the disease ; the irritability 
is excessive and peculiar, vomiting being induced by any movement, 
especially an attempt to sit upright, while there are no corresponding 
symptoms of gastric derangement ; for though the appetite is gone, 
the thirst may not be remarkable ; and the tongue is white and 
furred, but not red or pointed. Pain in the abdomen usually attends 
the complaint, and some tenderness on pressure over the epigas- 
trium ; but these fall far short of what indicate an abdominal inflam- 
mation. 

The complaints made of the head, and the expression of the coun- 
tenance, dispel all doubts as to the nature of the case. Pain in the 
head is loudly complained of, or the child (when unable to speak) 
clasps its hands round the head, while occasionally the screams are 
frantic; and alternately with these, there is a heaviness, or unwilling- 
ness to be stirred. During the periods when there is absence of the 
look of pain, or terror, that accompanies the more violent symptoms, 
the eye appears to be set, or vacant, with that look of dejection that 
belongs so peculiarly to cerebral disease. This is the form of hydro- 
cephalus that runs its course most rapidly, but regularly ; and in it 
the stages are most distinctly marked. The pulse, from having been 
strong and quick, becomes slow, weak, and irregular in its beats, or 
unequal : the great slowness and inequality now become remarkable ; 
but it is liable to be accelerated on any motion. Golis speaks of the 
pulse as being sometimes slow in the first instance ; but this is rare 
in the acute form of the complaint, although in the low or strumous 
variety, the pulse is at first almost always slow. Corresponding 
alterations take place in the other symptoms. Pain in the head is 
less complained of during the second stage : but this is not always 
so ; and there still continue occasional screams, or exclamations of 
suffering. The head droops or sinks upon the pillow, and is with 
difficulty raised ; and the fontanelle is often found at this period full 
or prominent. Heaviness or torpor prevails : the child lies in a coma- 
tose state, with its eyes half-closed ; and a slight paralysis of one of 
the upper eyelids is often present. The pupils are dilated or im- 
moveable ; and strabismus not unfrequently attends. An oscillatory 

* Dr. Armstrong, in his Lectures, says there is a "combined expression of phy- 
sical brightness and intellectual dulness in the eye;" and describes the •* inter- 
course" which naturally subsists between the eye of the infant and that of the 
mother or nurse, as being in this case lost. He lays much stress on these circum- 
stances, as indicative of cerebral inflammation in the child. 



2S4 DISEASES OF THE CEREBRAL SYSTEM. 

condition of the pupil may precede this state, with impaired or double 
vision. We have seen the pupil dilate on exposure to the light, and 
contract on its removal. The sickness of stomach now diminishes, 
or may be altogether absent, and some appetite occasionally returns ; 
but the child emaciates remarkably, the bowels continue obstinately 
costive, and there is incessant picking of the mouth and nose. The 
hands, which are often raised to the head, are observed to be tremu- 
lous in their movements ; the child moans ; and the state of debility 
is indicated by frequent sighing. 

This condition may continue for one, or even two weeks ; but the 
symptoms of the third stage now begin to manifest themselves, and 
add new distress to the scene. 

Convulsions, in all forms and degrees, may be present, from the 
most violent general convulsion to mere spasmodic twitching of the 
muscles of the face, or vibratory motions of the eyeballs. A rigid 
state of the muscles may be present ; and violent spasms of one 
side may continue to recur after the other has become paralysed : or 
the child will wave one hand in the air, or toss one leg about, while 
the other limbs lie immoveable. There is frequent grinding of the 
teeth, and movement of the lips and tongue. The whole appearance 
indicates extreme distress. The child lies moaning, or raving, yet 
insensible. The eyes are turned upwards, and constantly fixed in 
that position (a most alarming symptom); or the half uncovered eye- 
ball discloses a conjunctiva duly suffused, the pupil dilated, and the 
cornea dim and coated with a filmy matter. The skin is partially 
covered with profuse perspiration, while in other parts it is dry or 
burning hot. The pulse becomes excessively rapid, more so than in 
almost any other disease ; but this apparent effort at reaction soon 
gives way : the pulse grows gradually weaker ; the breathing be- 
comes unequal ; and the coma more profound. The child lies in a 
state of utter prostration, the abdomen being drawn in, and the limbs 
relaxed ; and dies in a state of collapse, or a violent convulsion pre- 
cedes death. The duration of this final or third stage is very vari- 
able, occasionally lasting for a week, or even fortnight ; at times not 
enduring for more than a few hours. 

The more common form of hydrocephalus is much less acute, and 
therefore the symptoms less strongly marked. Great lassitude, lan- 
gour, and irritability first begin to give character to the child's indis- 
position. It is restless ; dislikes light or noise ; is very averse to 
exertion ; totters in its walk, or drags one limb after it : and is soon 
fatigued in an attempt to sit up for any length of time, which it is 
unable to do. There is heat of head, and pain ; the pain being occa- 
sionally complained of in the eyes or back of the neck, and alternating 
with pains in the limbs or abdomen. There is some fever ; the con- 
junctiva of the eye is injected, or the pupil contracted. There is 
grinding of the teeth during sleep, and starting or screaming on being 
awakened ; but the intellect seems to be little disturbed ; for the 
child, though unwilling to be spoken to, replies correctly to questions 
asked. A sudden stammering, or faltering in the use of a particular 
word, is always to be Looked on as a serious symptom. The peculiar 



IXFLAMMATORY AFFECTIONS. 285 

irritability of stomach, and derangement of bowels before noticed, 
are present ; and the somnolency, deep sighing, the peevish shrill 
scream,* and peculiar expression of the countenance, so characteris- 
tic of hydrocephalus, complete the picture. The disease passes 
through its stages as before described, but not always in a marked 
manner : in particular, the pulse may be invariably fast throughout. 
The urine, which is scanty or suppressed, occasionally causes distress 
in passing. We should recollect that it may be retained, and an aggra- 
vation of the cerebral symptoms be induced by an over-distended 
state of the bladder. We have seen some cases in which a very 
copious flow of urine had preceded the establishment of the disease. 

In that variety of the complaint, described as the tubercular, but 
which is nothing more than the strumous variety in its most exqui- 
site form, the symptoms appear to observe a very uniform order in 
their course ; beginning with vomiting, then headache, and consti- 
pation. Somnolency is succeeded by delirium ; or they alternate 
with each other — coma now sets in, and convulsions follow. The 
expression of the countenance is very peculiar, and the respiration 
is observed to be accompanied by a kind of sign in expiration. The 
pulse, which is at first slow, becomes very much accelerated before 
death. 

A peculiar circumstance in the progress of hydrocephalus, and one 
well worthy of note, is the occasional remission or total disappear- 
ance of all alarming symptoms for a short period towards the conclu- 
sion of the disease, so that a child recovers the use of its speech and 
senses, noticing objects, and asking or answering questions ; but this 
remission (or " lighting up before death," as the nurses express it), 
is of short duration, a deeper state of insensibility than before sets in, 
and the expectations of recovery which the inexperienced or over- 
sanguine may have held out, are for ever put an end to. 

Chronic Hydrocephalus. — The head gradually enlarges in size in 
this form of the disease ; and the headache, fever, and other symp- 
toms which belonged to the more active stage subside ; or, as more 
generally happens, the disease arises insensibly without any ante- 
cedent acute stage. The head sometimes attains an immense magni- 
tude — the sutures being separated, the fontanelles transparent and 
full, with a distinct fluctuation perceptible on pressure, while the face 
retains its natural size, and gives to the physiognomy a very peculiar 
expression. In a few instances, instead of general enlargement of 
the head, a fluctuating tumour may be felt near the occiput. This 
is surrounded by the investments of the brain, so that upon pressure 
the fluid compresses the cerebral substance, and thus gives rise to 
coma or convulsions. The senses become blunted, and the intel- 
lectual powers impaired ; or altogether suppressed, as the disease 
advances. Muscular power is much enfeebled, so that the patient 
is unwilling or unable to move about ; and the enormously distended 

♦The peculiarity of this cry seems to have been first pointed out by M. Coindet, of 
Geneva, by whom it was assigned as evidence of effusion having taken place ; but 
erroneously. 



2S6 DISEASES OF THE CEREBRAL SYSTEM. 

head can no longer be supported, but droops upon the shoulder or 
the chest. This gradual diminution in the sensitive and locomotive 
powers, while the head increases in size, marks the progress of 
chronic hydrocephalus in the child after it has passed the first year 
of its age. Convulsions not unfrequently occur, and several of the 
other symptoms enumerated under acute hydrocephalus, but in a 
mitigated form. A variety of hydrocephalus, analogous to the 
chronic, may exist in the infant at birth, constituting the congenital 
hydrocephalus of authors. In these cases, the head is occasionally 
so much enlarged as to afford a serious impediment to delivery. 

In Arachnitis, confined to the base of the brain, there is fever, 
general languor, and depression. Pain is complained of in the fore- 
head or temples ; but the intellectual faculties are undisturbed. The 
head is hot ; the child moves it from side to side, or sinks it heavily 
on the pillow. Vomiting attends, and more or less of drowsiness is 
present. Spasm now begins to appear ; and in this affection, in 
particular, generally affects the mouth, the eyes, or the upper extre- 
mities. Frequent working of the tongue and lips, or motions of the 
lower jaw (machonnement) are observed ; or the hands and arms 
are convulsed at intervals, or for a long time together. A sudden, 
and often complete loss of the intellectual powers and senses, as well 
as of the general sensibility, at the same time occurs. We have often 
to notice in this affection, as we did in hydrocephalus, the occurrence 
of remarkable, but deceitful remissions of the symptoms. But con- 
vulsions again occur ; coma sets in ; the pupils become dilated ; the 
pulse very slow : and a state of complete relaxation of the limbs pre- 
cedes death. 

This affection is often accompanied by spinal arachnitis : which 
we judge of by the stiffness of the muscles at the back of the neck, 
and the pain complained of in this part. The head is often observed 
to be retracted, or moved from side to side : the former circumstance 
being considered as indicative of that part of the arachnoid which 
covers the pons Varolii being in particular implicated in the disease ; 
the latter, that the inflammation has attacked the upper part of the 
medulla oblongata. 

Children are not exempt from arachnitis of the upper surface of 
the brain, though this affection occurs less frequently with them 
than the other variety. In one remarkable case which we witnessed, 
a thick, tenacious layer of lymph was effused on the arachnoid of 
the anterior lobes of the brain. The child had been seized suddenly 
with severe convulsions ; the head continued hot, face red, and eyes 
suffused ; high fever followed, with delirium, violence of temper, 
general convulsive movements of the limbs, coma, paralysis, and 
death on the fourth day. A brother of this child was seized in a 
similar manner, when about the age of the former patient : but was 
seen early, and under the use of active depletion, the disease was 
arrested in its first stage. 

Pathology. — After the pathological remarks made at the begin- 
ning of this section, much does not remain to be said of the morbid 
conditions of the brain connected with hydrocephalus. These will 



INFLAMMATORY AFFECTIONS. 287 

vary according to the form and duration of the complaint. If the 
disease run a rapid course, and be of the acute inflammatory kind, 
little or no fluid may be effused ; and even the membranes may 
appear to be only slightly injected. In other cases, where water is 
not found, it appears to have been absorbed before death, as the 
ventricles are found dilated, though empty; and we know that such 
at times occurs with other dropsical effusions. The water effused in 
the very rapid attack already alluded to (p. 276), is usually found to 
be turbid or whey-like. Flocculi of lymph are occasionally seen in 
the serum; but in general, the water is limpid, of a light straw- 
colour, and not exceeding a few ounces in quantity. The average 
extent of the effusion may be estimated at four or five ounces ; occa- 
sionally it amounts to seven or eight, but in some cases of chronic 
hydrocephalus to much more, the fluid being generally of a deep 
citron colour. The mere circumstance of a small quantity of serum 
being found in the ventricles after death, is not to be looked upon as 
a proof that hydrocephalus had existed during life ; for such usually 
takes place previous to death in cases of protracted illness, or may be 
induced by the very means taken to avert it; as we doubt not, we 
have seen done by excessive depletion injudiciously employed in the 
cerebral affections of children. The fluid effused in hydrocephalus 
is usually situated in the lateral ventricles, which are in consequence 
distended, the dilatation being most remarkable towards the digital 
cavity. The foramen is often considerably enlarged ; but, in gene- 
ral, little fluid is found in the third or fourth ventricles. This effu- 
sion into the ventricles constitutes the hydrocephalus interims of the 
old writers — an unnecessary distinction, as it does not appear to 
have been established that hydrocephalus externus exists. The 
serum effused in hydrocephalus is often not coagulable by the action 
of heat or acids, or only very slightly so ; but this is not uniformly 
the case. In consequence of the distension of the cerebral substance, 
consequent on the effusion, we find the superior convolutions of the 
brain much flattened and depressed, or it may be stretched into a 
thin covering, a sense of fluctuation being perceptible on removing 
the skull. The vessels on the surface of the brain may be in a state 
of congestion, or the pia mater injected with blood ; but this is not a 
frequent appearance. The arachnoid on the convex surface is 
usually dry ; but beneath that, at the base of the brain, fluid is often 
found effused. When this is the seat of morbid action, the arach- 
noid will be dull, opaque, or covered with layers or granules of 
lymph ; but that lining the ventricles is often unchanged, though 
much fluid be effused. Laennec speaks of extensive tubercular 
deposition throughout the brain ; and Dr. Gerhard describes tuber- 
cular deposition on the membranes. We have certainly seen some 
cases of this description. The substance of the brain in acute hydro- 
cephalus is generally softer than natural, except in some cases which 
run a very rapid course. Ramollissement is most generally found 
in the central parts of the brain, in the fornix, corpus callosum, or the 
digital cavity. In chronic hydrocephalus there is incomplete ossifi- 
cation of the bones, with separation of the sutures, or in some cases 



28s DISEASES OF THE CEREBRAL SYSTEM. 

total absence of bony matter ; and in other cases, again, especially 
some that were congenital, a great expansion of the cranial bones 
has been observed. 

Of the secondary lesions, or complications, found after death in 
hydrocephalus, a morbid condition of the intestinal mucous mem- 
brane, or the liver, has been most frequently remarked ; and this 
coincides with the fact already noticed, of hydrocephalus originating 
so often in derangement or disorders of the digestive organs. The 
lungs, also, are not unfrequently found inflamed. 

Diagnosis. — The circumstances most characteristic of this disease, 
and which distinguish it best from others, are, — the particular ex- 
pression of countenance ; the peculiar cry or scream ; the variability 
and successive changes, in the character of the pulse ; the irritability 
of the stomach ; the costive state of the bowels, with a peculiar green 
appearance of the evacuations when obtained, and the suppression 
of urine, — cerebral excitement being succeeded by convulsions, 
coma, or paralvsis ; all which signs have been dwelt upon in describ- 
ing the symptoms of the disease. The occurrence of one or more of 
these symptoms, during the existence of infantile fevers, should lead 
us to apprehend hydrocephalus, which may occur either as a sequel 
to any of them, or commence, itself, with symptoms so similar, that 
the disease may be established before its existence is suspected, — 
there being, in fact, often no means of accurately distinguishing 
between simple remittent fever and the first stage of hydrocephalus. 
The same may be said of those disorders of the cerebral system which 
we have described under the name of functional ; for the establish- 
ment of a diagnosis between any of those and hydrocephalus, we 
must refer to our detail of the symptoms of both, and recommend a 
careful collation and comparison of these in every individual case. 
We must often, however, expect great difficulty in ascertaining, in 
any particular instance, whether convulsions, or symptoms of irrita- 
tion of the brain, or of the hydrencephaloid disease, are purely func- 
tional, or must be referred to organic lesion. Whenever doubt exists, 
it will probably be encountering the least hazard to consider that the 
latter is present. 

The symptoms of chronic hydrocephalus are so well marked, as 
sufficiently to distinguish it from other diseases. With respect to 
the other varieties of the complaint, as the various forms of arach- 
nitis, &c, their diagnosis from each other must be attempted by a 
comparison of all their symptoms ; a matter always of much diffi- 
culty. 

The Prognosis must be in all cases guarded, but, even in those 
apparently the worst, need not be hopeless. We have seen that the 
most alarming symptoms may exist, without these being certain proof 
of any irreparable lesion ; and, notwithstanding such symptoms, 
recovery may take place. When the cerebral symptoms have come 
on insidiously, however, at the sequel of a previous disease, in a child 
of a strumous habit, or one having a family predisposition to the 
disorder, much danger is to be apprehended, and the result is most 
frequently fatal. The more acute the inflammation, on the contrary, 



INFLAMMATORY AFFECTIONS, 2g9 

the greater in general is the chance of cure, and the better is active 
depletion borne, — such cases usually occurring in healthy children. 
Recovery may also be generally effected, when the disease sets in 
subsequently to scarlatina, if we are prepared to meet the case, as 
the symptoms are often very sudden and acute. That form of the 
disease which is connected with inflammation of the arachnoid at 
the base of the brain is very dangerous, as alterations of structure, 
and the growth of false membranes, are so liable to occur. That 
variety of chronic hydrocephalus which succeeds to an acute attack, 
is almost always fatal ; but its more common form, when once 
established, does not seem of itself directly to shorten life, — the 
patient generally dying of some other disease : Golis thinks this form 
of the complaint may frequently be cured. When coma, convulsions, 
or delirium, attend upon chronic hydrocephalus, or an acute attack 
supervenes, the disease generally proves fatal. Congenital hydro- 
cephalus is almost invariably incurable. 

The condition of the secretions, and the pulse serve, in particular, 
to guide us as to our prognosis in any particular case. When the 
bowels become easily moved, while the evacuations grow natural, 
the flow of urine increases, or a copious warm perspiration breaks 
out, we have very favourable signs ; and with these, some running 
at the nose is occasionally observed. As to the pulse, Cheyne says, 
' that so long as it continues steady, while the breathing is natural, 
we should not be deterred by other symptoms, however formidable, 
from entertaining expectations of recovery.' When the pulse falls 
suddenly, however, and remains slow, until it again arises with ex- 
traordinary rapidity, while the breathing becomes unequal and irre- 
gular, we augur very unfavourably, seeing that the case runs on 
through the usual stages. We must be careful to distinguish between 
the gradual diminution of the pulse, indicative of a subsidence of 
fever, and this sudden fall or protracted slowness connected with the 
second stage of the disease. As careful must we be to distinguish 
between those deceitful and temporary remissions in the symptoms 
already alluded to, and the protracted improvement of some days' 
duration, which we may rely upon as indicative of recovery. So 
long, however, as the pupil continues dilated, or is very slow to con- 
tract, we must dread relapse, even though recovery may have appa- 
rently taken place. The spontaneous occurrence of a cutaneous erup- 
tion has in some instances appeared to expedite recovery, in pro- 
tracted cases ; but a particular kind of eruption, consisting of almost 
imperceptible vesicles, is occasionally observed to occur on the face 
or upper parts of the body, towards the end of the disease, and is to 
be looked upon as an unfavourable sign. Continental writers men- 
tion this eruption as a constant attendant on hydrocephalus, but it is 
seldom noticed in this country. 

Treatment. — In undertaking the treatment of a case of hydro- 
cephalus, we must be guided by the form of the complaint, and the 
stage or period at which we see it. In the acute attack, when re- 
cently seen, our treatment must be actively and perseveringly anti- 
phlogistic. Bloodletting, purging, and cold applications to the head, 
25 



290 DISEASES OF THE CEREBRAL SYSTEM. 

with subsequently the use of counter-irritation, constitute our chief 
resources, and their full employment will often prove successful. In 
the low form of hydrocephalus, or when the disease is chronic, active 
depletion is not admissible, though the moderate use of antiphlogistic 
measures may be occasionally called for ; but we cannot expect here 
to effect a cure, merely by active depletion, as may be done in the 
other form of the complaint. Leeches occasionally, and in all cases 
cold to the head, followed by active counter-irritation, while we keep 
the bowels open, or try to improve the secretions by alterative doses 
of mercury, appear to be the means on which most reliance is to be 
placed, in these forms of the complaint ; while we at the same time 
take care to support the strength by a sufficient supply of light but 
nutritious food. 

Bloodletting should be carried to such an extent, when first em- 
ployed in the acute variety, as to make a decided impression : and 
general bloodletting may require to be repeated, but the substitution 
of leeches will frequently answer. In the less acute or more pro- 
tracted form of the disease, a frequent repetition of the leeches may 
be required ; although the application of a large number on any one 
occasion would not be advisable. When the hydrocephalic symp- 
toms occur during the existence of disease of the lungs, or particu- 
larly of the digestive organs, the application of leeches over the seat 
of the original disorder will often more effectually relieve the head 
than if they were applied directly thereto. 

Mercury has been employed specifically in the treatment of hydro- 
cephalus, but its use has been much overrated. In the acute form, 
the constitutional action of mercury, after bloodletting, has certainly 
aided in cutting short the disease, as we see occur in other internal 
inflammations ; but in the low or strumous variety of the complaint, 
the production of salivation does not appear to exercise any special 
influence in controlling the symptoms ; for though these may be 
mitigated thereby, the case will generally proceed to a fatal ter- 
mination. Small doses of calomel, given so as to act as an alterative, 
appear to effect all the good thatt can be looked for from mercury, 
in this form of the complaint ; which good seems to arise from 
the improvement thus effected in the condition of the digestive 
organs. 

In chronic hydrocephalus, Golis regards this plan of treatment, 
aided by counter-irritants to the head, as the best that can be pursued, 
and states that it is often successful ; but condemns the employment 
of the large doses of mercury commonly in use. Corrosive sublimate 
has been occasionally employed with success. 

In either of these forms of hydrocephalus, however, and even in 
the second stage of the acute variety, we much prefer the use of 
iodine to that of mercury, and have seen some cases of its signal 
success. Iodine, to be effectual, however, must be largely employed, 
both internally and externally. The combination of iodine with 
mercury, in the proto-ioduret, would seem to present particular ad- 
vantages. The ointment of bin-iodide of mercury appears eligible 
for producing speedy and effectual irritation over the scalp, while it 



INFLAMMATORY AFFECTIONS. 091 

at the same time has a tendency to affect the constitution, so as to 
induce salivation. 

The tonic or stimulant properties of iodine have also their advan- 
tage in the treatment of hydrocephalus, under these circumstances ; 
and its diuretic power may enable us to dispense with digitalis, squill, 
&c, &c., — once of much repute, but little to be relied on in the treat- 
ment of this disease. 

Digitalis is an unmanageable medicine in affections of the head, 
and its diuretic powers particularly uncertain in hydrocephalus. It 
should never be employed in the acute form or earlier stages of the 
disorder ; but in chronic hydrocephalus, or that variety occurring in 
connection with anasarca after scarlet fever, frictions with tincture 
of digitalis, or squill, extensively appliedover the surface of the body, 
appear to have been practised on the Continent with some success. 

Purgatives are of great service in the early stages of hydrocepha- 
lus, especially when presented in the acute form; but their employ- 
ment requires judgment and caution. 

In general it is very difficult to move the bowels in this complaint, 
and the most active purgatives may be required ; but in consequence 
of the irritable state of the stomach, we shall often be obliged to 
resort to enemata to effect this purpose. Purgatives after bloodletting, 
however will often produce free evacuations, although they had 
before failed to move the bowels. When irritation of the intestinal 
mucous membrane is present, we must be careful to avoid active 
aperients, and rest satisfied with mild enemata. 

Antimonials will be found of much service in mitigating increased 
cerebral action, and have been used with advantage in the early 
stage of hydrocephalus by Cheyne and Mills. Vomiting should, 
however, be guarded against ; but Laennec has proved that tolerance 
of tartar emetic can be attained in affections of the head. James's 
powder is a more manageable preparation, and may be given alone, 
or combined with calomel or cathartics. 

Opium, employed after bloodletting and purging, alone, or in com- 
bination with antimony or ipecacuan (as Dover's powder), is often 
of great service, particularly in the second, or even third stage of the 
disorder, by lessening the frequency of the convulsions, allaying 
pain, and even rendering the pulse more full, and less irregular. 
The use of opium, when once commenced, should not be suddenly 
discontinued ; but when contraction of the pupil ensues from its 
employment, this is to be looked on as a sign that the use of the 
medicine has been carried far enough ; nor should we attempt to 
control the convulsions sometimes attendant on the inflammatory 
stage, by opium, independently of antiphlogistic means. 

During the progress of hydrocephalus, we must not forget the 
necessity for supporting the strength ; and in the advanced stages, 
light bitters, tonics, or even stimulants may be required. Strong 
coffee or tea will at times dissipate coma, rouse the circulation, and 
restore warmth to the skin. Direct stimulants, as ammonia, ether, 
camphor, or musk, will in come cases be required ; and particular 
efficacy has been assigned by some practitioners to certain medicines, 
as the calamus aromaticus, serpentaria root, arnica montana, &c; 



292 ERUPTIVE FEVERS. 

but their utility is not sufficiently established. A large blister applied 
over the head is often of great service at this period. 

When distinct intermissions are to be noticed in the progress of 
the complaint, indicated by alternations in the heat, and chills of the 
surface, flushings and paleness of the face, with excitement and 
depression of the animal powers, M. Piorry specially recommends 
the use of Peruvian bark, given in the form of enemata, and to the 
extent of from two scruples to two drachms at a time. The period 
for exhibiting the bark is during the time of intermission, when the 
face is pale and system low ; and the bark in substance was found 
to be much preferable to quinine. 

In the treatment of chronic hydrocephalus, principal attention 
must be paid to support the strength, while we at the same time 
improve the general health. Counter-irritation must be freely and 
frequently applied to the head, and setons or issues inserted in the 
neck. Warm baths* are of much assistance ; and we may avail 
ourselves of the alterative action of mercury, or the specific influence 
of iodine, in attempting to cause absorption of the effused fluid. 
Antiphlogistic measures may be occasionally necessary ; but should 
never be intemperately employed. Compression of the head has 
been used to assist the action of the absorbents in diminishing the 
effused fluid ; or this has been in some cases evacuated by puncture, 
tapping the head having been resorted to with success in a few 
instances.! 

To prevent the occurrence of hydrocephalus in children predis- 
posed thereto, we should place them in a dry, warm, and elevated 
situation ; avoid all causes of mental excitement, in particular early 
or excessive exercise of the intellectual faculties ; and as medical 
measures, pay especial attention to the state of the bowels and regu- 
lation of the diet. An issue kept open in the arm or neck, during 
childhood, has undoubtedly exercised a control in averting hydro- 
cephalus in families predisposed to the disease. 



CHAPTER XI. 

ERUPTIVE FEVERS — (EXANTHEMATA). 
I. MEASLES — (RUBEOLA; MORBILLl). 

This exanthem consists in a fever, in which the mucous membrane 
of the air passages is chiefly affected, and which, after about three days' 

* In Continental practice the use of medicated baths is much relied on in the 
treatment of chronic hydrocephalus. Alkaline solutions seemed to be preferred by 
Golis ; but Recamier and Andrieux recommend tartar emetic (one ounce gradually 
increased to four or five in each pailful of water), which appears, when thus em- 
ployed, to cause a copious flow of urine, the patient growing thin, and the size of 
the head at the same time diminishing. 

f Cases are recorded by Dr. Conquest, see Lancet for 1830 ; by Mr. Lizars, in 
Edin. Med. and Surg. Jour.; by Dr. Vose, in the Med. Chir. Tran. vol. ix. ; and 
others. 



MEASLES. 293 

duration, results in the eruption of a red rash over the surface of the 
body. 

Symptoms. — Measles commences with the ordinary signs of fever 
— langour, shivering, heat of skin, thirst, &c. ; and at the commence- 
ment cannot be distinguished from common catarrh, or other febrile 
affection. As the disease advances, the catarrhal symptoms become 
very distinct ; there is dry, hoarse cough (often much resembling that 
of croup); frequent sneezing; suffused and watering eyes; swoln 
and feverish face ; alternations of heat and chills ; quick pulse ; thirst, 
and scanty secretion of urine ; with hot, dry skin. There is occasion- 
ally vomiting or purging, but sometimes constipation of the bowels. 
These symptoms occur, with greater or lesser severity, in different 
cases ; being sometimes very slight, and scarcely attracting attention ; 
at others, exceedingly severe, — being accompanied with delirium, 
and the affection of the lungs amounting to actual inflammation. 
There is usually, towards evening, an exacerbation of all the febrile 
conditions. 

After the symptoms enumerated have continued for three or four, 
or in some cases for so many as seven or eight days, the eruption 
begins to appear in the form of round, red dots — showing first upon 
the forehead and face, and subsequently upon the body and limbs. 
On the fifth day, the whole surface is usually covered with the erup- 
tion ; which begins to decline on the face, on the sixth, and has usually 
disappeared altogether upon the tenth day from the commencement 
of the fever, or sixth from its own first appearance. The eruption is 
not confined to the skin ; but extends also to the mucous membrane, 
as we may observe by inspecting the fauces and mouth, upon which, 
reddish, slightly elevated spots will be discernible about the fourth or 
fifth days. The rash consists at first of separate elevations, giv- 
ing a sensation of hardness to the fingers ; subsequently, these 
run together into raised patches, of an irregular or semi-circular form. 
These patches are in healthy measles of a lightish red colour, and 
contrast strongly with the sound skin between them, which retains 
nearly its natural hue. At the termination of the disease, the cuticle 
covering these elevations becomes detached in the form of scales ; 
and during the desquamation, a troublesome itching is occasioned. 
Billard describes the eruption of measles as not feeling elevated above 
the surface, which is decidedly contrary to the fact.* 

Variations from the course of the eruption, as we have just de- 
scribed it, may occasionally occur; e. g., it may be accelerated or 
retarded in its course, or be combined with an eruption of miliary 
vesicles. In favourable cases, the violence of the fever abates as 
soon as the eruption appears ; but frequently the cough will continue 
without much fever for a considerable period. 

Pathology. — With respect to the cause and intimate nature of 
measles, or indeed of any of the other diseases included in 
this chapter, we are in a state of total ignorance ; and yet, to the 
philosophical physician, they are the most remarkable of any to which 

* Traite des Maladies des Enfans, p. 102. Paris, 1828. 
25* 



294 



ERUPTIVE FEVERS. 



the human body is liable. They are, indeed, well ascertained to be 
subject to certain definite laws, to a degree of strictness unknown in 
any other affection, — and which almost confirms to them the cha- 
racter of natural and necessary movements in the system, rather than 
of accidental diseases. 

These laws are ; first, that the proper period for the occurrence of 
the exanthemata is in the commencement of life — a rule to which 
we certainly meet with exceptions ; but not to an amount at all cal- 
culated to weaken the generality of its application. Secondly, that 
they occur but once in the same individual ; and to this the excep- 
tions are extremely rare, although not totally wanting. Thirdly, 
that they run a certain definite course as to order of symptoms and 
duration, to occasion any deviation from which, a very considerable 
disturbing force is required. Fourthly, that they afford the only certain 
examples of the propagation of disease by contagion ; but that, at the 
same time, they are in their own essence decidedly of an epidemic 
nature, — occurring at certain seasons of the year, usually in spring 
and the commencement of summer ; and at those times often arising 
in communities, independently of any traceable contagion. Fifthly, 
they have the power of suspending each other's action, although 
apparently owing to some degree of relationship or connection : thus 
epidemics of measles and small-pox commonly occur simultaneously ; 
but the progress of small-pox, after it has been received into the con- 
stitution, may be suspended by an invasion of measles, and may 
subsequently resume its course after the latter has terminated : and 
vice versa. 

A consideration of the foregoing laws, whose existence is univer- 
sally admitted, cannot but strongly force upon us the conviction, that 
in them we might hope to find some principia for the establishment 
of a true and comprehensive pathology. In the exanthemata, for 
example, we have instances of disease occurring, we may say with 
certainty, to all individuals ; and thence affording the presumption 
that by their operation a certain necessary change is effected in the 
system. Their usual occurrence at certain seasons, and their occa- 
sional suspension of each other, favour the same presumption ; as 
well as the immunity from future attacks conferred by them. The 
capability of being communicated by inoculation, belonging to some 
of them, also gives the means of experimenting upon disease, and so 
testing conclusions at which we might arrive by other channels : and 
we have also in them an opportunity, which is to be found under 
no other circumstances, of investigating the subject of contagion. 

To do more than hint at the foregoing views, would be, at present, 
out of place ; but our notion of their importance, induces us to ex- 
press regret, that the (perhaps too complete) abandonment of the 
doctrines of the humoralists, by leading to an almost exclusive con- 
sideration of the effects rather than of the working of disease, has 
somewhat diverted attention from the study of the exanthematous 
fevers. 

In enumerating the laws just stated, we have recorded nearly all 
that is known respecting the pathology of these affections. A latent 



MEASLES. 295 

period probably exists between the time of receiving the infection, 
and the appearance of the fever ; but the duration of this is not well 
ascertained, and is differently stated by authors — the average is 
probably about eight or ten days. 

Diagnosis. — Measles is to be distinguished by the regular occur- 
rence of the stages, and of the eruption, as we have described them. 
During the febrile stage, the disease can only be guessed at from 
collateral circumstances, — as exposure to infection, or the existence 
of an epidemic. The eruption must be discriminated by its peculiar 
characters, and by its occurring in connection with the febrile stage. 
The varieties of strophulus or red gum, have been sometimes mis- 
taken for measles ; but may be recognised by the absence of fever 
and catarrhal symptoms. 

Prognosis. — Measles, by itself, is not a dangerous disease : but 
in forming a prognosis, we must take into account the liability to 
complication with other diseases, as inflammation of the lungs or 
brain ; and also the sequelae likely to remain in the form of ophthal- 
mia, scrofula, diarrhoea, or phthisis. These, though not properly 
parts of the disease, are so likely to be called into action in patients 
predisposed to them, that we should always watch measles jealously, 
and speak guardedly of its termination : we must also be influenced 
in our opinion by the character of the prevailing epidemic ; which 
may at times assume even a malignant cast, and at others be ex- 
traordinarily mild. These circumstances, and the state of the patient's 
general health at the period of receiving the infection, must all be 
taken into account in forming our prognosis. 

Treatment. — In simple measles, the treatment must be rather 
preventive than remedial, and should be directed to the allowing of 
the disease to run its course without interruption or attempts at 
acceleration. Perhaps we cannot have a better plan than that adopted 
by Sydenham with the children of " the most virtuous Countess of 
Salisbury," viz. : " I ordered them to keep their beds two or three 
days before the eruption, that the blood, according to its own genius, 
might cast out through the pores the particles that were easily sepa- 
rated, which occasioned the disease ; but I did not permit that they 
should have any more clothes on, or fire, than they used to have 
when they were well. I forbad the eating of flesh, and allowed 
them oatmeal and barley broths, and now and then a roasted apple ; 
and for their drink, small beer, and milk boiled with three parts of 
water ; and when the cough was troublesome, as was usual, I pre- 
scribed a pectoral ptisan,* to be taken often."! So far as positive 
treatment is required, little more is necessary. If the bowels be 
confined, a gentle aperient (as No. 21 or 28, p. 126-7,) may be ad- 
ministered ; but in ordinary cases, no active purgatives are required. 
Every thing heating should be avoided; and in this country, as in 
the days of Sydenham, particular attention is required, in order to 

* For a suitable expectorant mixture, see p. 113. 

-j- Sydenham. Pechey's Translation. London, 1734. 



296 ERUPTIVE FEVERS. 

prevent the attendants from giving ardent spirits and stimulant 
drugs, with the view of " striking out the eruption, and driving the 
disease from the heart." The tenderness of the eyes belonging to 
the disease will, probably, make light disagreeable to the patient ; 
and if so, the room should be partially darkened, but at the same 
time free ventilation should be provided for. When there is much 
heat of surface before the eruption has appeared, we have found 
great advantage from sponging the body with warm vinegar and 
water ; and the same process will also materially relieve the dis- 
agreeable itching attendant upon the desquamation of the cuticle at 
the close of the disease. 

So much for the management of simple measles. Anxious atten- 
tion must, however, be directed towards any symptoms of local 
inflammation which may arise. The state of the respiration must 
be carefully watched, and the chest regularly examined ; and should 
any symptoms of bronchitis or pneumonia be discovered, very active 
treatment, perhaps even a repeated use of the lancet, may be required. 
Any symptoms of an attack in the head, as headache, remarkable 
intolerance of light, or convulsions, must also be narrowly looked 
after, and treated according to the principles laid down in the chapter 
on those affections. Local inflammations and congestions commonly 
appear as a kind of metastasis, suddenly setting in simultaneously 
with a sudden premature disappearance, or partial fading of the 
eruption ; and when such is the case, an important part of the treat- 
ment must be directed to the bringing out again of the rash. We 
have occasionally seen this effected, and the local affection quickly 
relieved, by placing the lower extremities and hips of the child, for 
five or ten minutes, in a bath of as high a temperature as could be 
borne. The partial hot bath, when used in this way, will almost 
always be found of service ; but we must be very cautious in attempt- 
ing to recall the eruption by the use of any internal stimulants. 
Most commonly these are contraindicated by the existence of active 
inflammation ; and in such cases the proper plan is the reduction of 
the latter by suitable depletion. 

It is not to be forgotten, however, that cases do occur in which 
the retrocession of the rash is occasioned by debility, either belonging 
to the type of the prevailing epidemic, or occurring accidentally in 
an individual patient. In such a case, we shall find the child cold 
and stupid, with pallid, shrunken features, and perhaps petechia?. 
When the chest is the seat of the metastasis, our diagnosis will be 
much aided by the employment of auscultation ; but it is often an 
extremely difficult point to decide as to whether the state of depres- 
sion, in which we may find a child, be dependent upon inflamma- 
tory congestion, or debility. These are matters, however, which fre- 
quently embarrass the most experienced physician, and can only be 
learned by long-continued personal observation of disease. 

When debility is obviously present, wine and stimulants (as the 
mixture No. 6, p. 98,) will be required ; and in such cases we have 
found advantage from the application of a blister, or stimulating em- 



MEASLES. 29? 

brocation ; but the rules laid down in the section treating of these 
remedies (p. 107), must be strictly adhered to. 

Severe purging is not an uncommon sequela of measles, and was 
treated with bloodletting by Sydenham, upon the theory that it 
arose u from vapours of inflamed blood rushing upon the guts." The 
theory is valuable, as being calculated to remind us of the existence 
of inflammatory diarrhoea, with tenderness of the abdomen, and 
fever ; but we are not to suppose that bleeding is necessary or ad- 
visable in every case of purging after measles. Most commonly it 
will be removable by alterative aperients (as No. 29, p. 127,) when 
the discharges are foul ; or it may require astringents, if the stools be 
watery, and the abdomen drawn in and empty. 

Varieties of Measles. — An eruption precisely similar in appear- 
ance to that of measles is occasionally seen, especially in young 
infants, and runs through a regular course, but without catarrhal 
symptoms. This has been denominated Rubeola sine Catarrho. 
It requires no particular treatment, being merely a local affection ; 
but it is generally believed by authors that it does not, like true 
measles, confer an immunity from future attacks.* Many rashes of 
this kind, sometimes denominated Roseola, sometimes distinguished 
by the above-mentioned name, occur during infancy and childhood, 
dependent upon dentition or derangements of the digestive organs ; 
but unless accompanied by the specific fever, and running the regular 
course, they are not to be looked upon as measles. 

Rubeola nigra is mentioned as another variety of measles, in which 
the rash assumes a peculiarly dark hue. Sydenham attributes this 
appearance to the employment of stimulants and a hot regimen. He 
observes, that it only happens to grown people, and requires prompt 
measures of depletion. We have seen this character given by the 
conjunction of petechise with the eruption of measles, when a typhoid 
epidemic was prevalent — under which circumstances, a stimulant 
regimen and treatment will be demanded ; in short, a management 
similar to that required in other low malignant fevers. 

Inoculation of measles has been proposed by Dr. Home, of Edin- 
burgh,! and was performed by him with blood drawn from a por- 
tion of skin affected with the rash. It has been performed by others 
in the same way, and also with lymph from one of the miliary 
vesicles which occasionally appear in the disease. In both ways, 
the affection appears to have been communicated, but not with much 
certainty, and the practice has not met with any general approval. 

* During an epidemic of measles which occurred in this city during- the latter 
part of last year (1839), we observed the Rubeola sine Catarrho under peculiar cir- 
cumstances such as we do not recollect to have seen noticed by any author. In one 
family of four children all underwent an eruption accurately resembling measles, 
in its external character and period of duration ; but without any fever or other 
constitutional derangement. All these individuals were attacked with genuine 
measles in the course of a week after the disappearance of the first eruption, and all 
passed through it favourably. We observed a similar occurrence in other isolated 
cases. [Note to 3d Edition.] 

f Medical Facts and Experiments, by Francis Home, M.D. London, 1759. 



298 ERUPTIVE FEVERS. 



II. SCARLET FEVER (SCARLATINA). 

This name is applied to an eruptive fever, which about the second 
day results in the appearance of bright red patches upon the skin 
and mucous membrane of the mouth and throat, commonly declining 
about the fifth day. The symptoms vary so much with the type of 
the fever in different attacks and epidemics of this disease, that we 
must describe them under separate heads, as constituting distinct 
varieties of the affection. 

a. Symptoms of Simple Scarlatina. — These are, at first, the 
ordinary symptoms of fever, viz., — lassitude, shivering, succeeded 
by heat, thirst, quick pulse, and occasionally nausea, headache, or 
even delirium. These vary much in degree in different cases, from 
the slightest disturbance of the constitution to severe fever. About 
the second day (according to Sauvages and Cullen, not until the 
fourth), the eruption appears in the form of red spots — first upon 
the face and neck, and subsequently these coalesce and spread over 
the trunk and extremities. On the third day the eruption is at its 
height, and then appears in the form of a continuous bright redness 
upon the extremities, and of large irregular patches upon the trunk 
of the body. It has been likened by Huxham to the colour produced 
by smearing over the skin with the juice of raspberries. The red- 
ness is paler in the morning, and assumes its greatest brightness 
towards evening. The skin subject to it is dry and very hot, but it 
gives to the touch no feeling of elevation, only a slight sense of 
roughness. It may, however, occasionally be intermingled with 
miliary vesicles, or papulae, especially when the patient has been 
subjected to a stimulating treatment or regimen. The eruption may 
also be seen upon the inside of the mouth and throat, which assumes a 
bright scarlet colour : the tongue, if clean, exhibits the same hue, or 
the papillae appear through the coating of fur, and their redness, as 
well as that of the tip, affords a strong contrast to its white or yellowish 
colour. Dependent upon the occurrence of the eruption in the fauces, 
there is always more or less sore throat. On the fifth day the 
eruption usually begins to decline, and in a day or two after altogether 
disappears — its departure being attended with a general desquama- 
tion of the cuticle from the whole surface of the body. 

The foregoing is a description of the mildest form of scarlatina, 
which Sydenham terms but " the name of a disease." If, however, 
as that admirable physician states, it be treated " too learnedly," or 
if the invasion be in its own nature more severe, all the symptoms 
may be materially aggravated, and a dangerous disease presented to 
us. By some, such an aggravation of character has been considered 
to constitute a distinct variety, which they have described under the 
name of Scarlatina rfnginosa ; but the distinction is unnecessary, 
the difference being rather in degree than in kind, and the slighter cha- 
racter of the symptoms being convertible into a severer, merely by mis- 
management ; or peculiarity of constitution. The symptom of sore 



SCARLET FEVER. 299 

throat, to which the term anginosa refers, is common, in a greater or 
lesser degree, to all forms of scarlatina. 

The principles of treatment, also, must be the same ; whether the 
disease be mild or severe ; provided only it be inflammatory, and 
there should be no difference, except in the degree to which we may 
find it necessary to work them out. We conceive, in short, that less 
confusion will be created, and a right understanding of the treatment 
facilitated, by considering as identical in nature, and only different in 
degree, all cases of the disease which possess inflammatory or sthenic 
characters, thereby including under one head the Scarlatina, Sim- 
plex and Jlnginosa, of most writers, and Dr. Armstrong's Inflamma- 
tory Variety of the Scarlatina Maligna. 

All the symptoms, then, which we have described may exist in 
an aggravated degree ; the fever may be more violent, with quicker 
pulse, greater headache, and more frequent delirium. The skin may 
be much hotter, amounting sometimes to 106° or 108° F. There 
may be considerable derangement of the digestive functions, with 
oppression at the praecordia, vomiting, and dark stools. The soreness 
of throat, which in mild cases demands little attention, may be very 
severe and distressing, with pain and stiffness about the neck, painful 
deglutition, hoarseness, and a viscid secretion of mucus, causing much 
suffering by the efforts constantly excited for its expulsion. Upon 
looking into the throat, we may find considerable redness and swelling, 
and often, portions of lymph thrown out upon the tonsils and uvula, 
which may at first be mistaken for ulcers or sloughs of the mucous 
membrane, but are not so, as upon their removal by gargling, the 
latter will be perceived to be whole and unbroken. When the 
symptoms run to the height which we have just described, there is 
usually much nervous excitement, and the supervention of in- 
flammation of the brain or other viscus is to be dreaded. Thus, 
after delirium and high cerebral excitement, the patient may suffer 
collapse, and ultimately sink into a state of coma, showing that con- 
gestion has taken place within the head. In other cases there may 
be diarrhoea and vomiting, with tenderness of the abdomen, indica- 
ting an inflammatory condition of the alimentary canal ; or there may 
be fatal inflammation of the respiratory organs. Fatal gangrene of 
the throat may also supervene even upon the most inflammatory at- 
tacks of scarlatina ; or acrid discharges may take place from the nos- 
trils, causing sores about the lips and corners of the mouth. These 
latter circumstances may occur as a sort of secondary attack, upon the 
eighth or ninth day, after the patient has, apparently, got through 
the disease : thus, being somewhat analogous to the secondary fever 
of small-pox. In severe attacks, there may be irregularities in the 
eruption : it may appear too soon ; or it may be retarded ; or, lastly, 
it may recede, or become faint too soon after its first appearance. 
When the fever has been violent, the desquamation is occasionally 
very remarkable, the whole cuticle peeling off the hand or foot in the 
form of a glove or sock. 

As sequelae of scarlatina, we frequently have dropsy, either in the 
cellular membrane, or in the cavities ; also, abscesses in various situa- 



300 ERUPTIVE FEVERS. 

tions ; ophthalmia ; suppuration from the ears ; and various forms of 
scrofula. The dropsy most commonly affects the cellular membrane, 
especially of the hands, feet, and face ; but it sometimes takes place 
in the cavities. A dropsical swelling of the hands and feet may 
follow very mild cases of the disease, setting in a week or ten days 
after the disappearance of the rash. It is attended by symptoms of 
an inflammatory kind, the pulse becoming quick, the stomach 
deranged, with costive or irritable bowels, nausea, and scanty, high- 
coloured urine. When the face is affected, its pallor, and the swell- 
ing of the eyelids, give the patient a peculiarly bloated and unhealthy 
aspect, More rarely, effusion takes place into the head, chest, or 
abdomen ; and it is then also of a more dangerous character — some- 
times rapidly occasioning death. The urine in dropsy after scarlatina, 
is generally albuminous, and coagulates upon the application of 
heat. 

b. Symptoms of Malignant Scarlatina. — Under this head, we 
shall consider the asthenic forms of scarlatina, or those in which the 
fever is of a low, typhoid type, whether that be occasioned by pecu- 
liarity in the prevailing epidemic, or bad state of constitution in the 
individual patient. Such forms of disease have been described by 
authors under different names, as Angina or Cynanche Maligna, An- 
gina Gangrenosa, or putrid ulcerous sore throat. Malignant scarla- 
tina is a most formidable disease, often sweeping away all the chil- 
dren of a family, in spite of the most judicious and zealous attentions 
of the physician. 

In many cases the symptoms are, at first, similar to those already 
described ; the patient being seized with severe headache, shivering, 
quick pulse, and other indications of fever, which, however, soon 
assumes a typhoid character. The pulse becomes very rapid and 
irregular, the heat of surface unequal ; and a low muttering delirium, 
with great restlessness, sets in. In other instances Huxham* describes 
the patient as " moving about for a day or two, neither sick nor well, 
as it were, but under uneasiness or anxiety, till they were obliged to 
lie for it." There is usually great dejection of spirits, sudden pros- 
tration of strength, and heaviness about the breast ; the countenance 
is pale, sunk, and dirty ; the eyes red and heavy ; the tongue loaded 
with a brown fur, or unnaturally clean, and of a fiery red colour. 
There is commonly nausea ; often severe and protracted vomiting 
and purging ; the discharges from the bowels, and the urine are 
much deranged — the former being, in children, usually loose, dark- 
coloured, and fetid ; the latter scanty, brown, and turbid. There is 
hoarseness, pain in swallowing, and painful swelling of the glands 
in the neck. The fauces appear somewhat swollen, and at the com- 
mencement, of a dark red hue ; but whitish or ash-coloured sloughs 
soon appear upon the tonsils and uvula, and the breath and odour of 
the body become very fetid. The rash in malignant scarlatina is 
irregular in its character and occurrence, being often faint or of a 
dark livid red colour, or interspersed with the petechias, but it may 

* Essay on Fevers, &c. London, 1757. 



SCARLET FEVER. 



301 



assume a bright scarlet hue. It also sometimes disappears soon after 
its first coming out, and it may return again in some hours or days. 

As the disease proceeds, all the symptoms are aggravated : there 
is extreme despondency and low delirium, or the patient sinks into 
a state of stupor. The sloughs in the throat spread and become 
dark-coloured and obviously gangrenous ; the voice is hollow and 
hoarse, and the breathing accompanied by a peculiar rattling, as if 
from strangulation. The patient is constantly harassed with efforts 
to spit up the sloughs, mixed with mucus, and often with blood. 
The disease extends to the nostrils ; and an acrid, ichorous discharge 
is emitted, which excoriates the lips and cheeks of the child, and, 
according to Huxham, even the fingers and arms of the nurse. The 
swallowing of this matter, also, appears to cause irritation in the 
bowels, and a species of dysentery. Towards the end, the breath- 
ing becomes difficult, the tongue black and dry, and discharges of 
blood occasionally take place from the several passages, the patient 
sinking exhausted at different periods, varying (according to his 
original strength, or the violence of the malady) from the third or 
fourth day to the second or third week : total insensibility or con- 
vulsions may precede dissolution. 

In some instances malignant scarlatina will prove fatal upon the 
second or third day, or even earlier, without the occurrence of death 
being explainable either by the progress of the gangrene of the throat, 
the amount of the typhoid symptoms, or the existence of any local 
congestion. Life, in these cases, appears to be at once extinguished 
by an intense impression upon the nervous system in a manner 
analogous to, but equally unexplainable with, what occurs in cholera, 
and more rarely in the cold stage of intermittent fever; the vital 
principle being, as it were, suddenly discharged from the body. Dr. 
Armstrong* also relates cases in which " children, and even adults, 
some time after exposure, now and then die suddenly, from the oper- 
ation of the contagion, without any appearance of efflorescence or 
of sore throat. They are attacked with convulsions, or with the 
symptoms of apoplexy, and frequently sink into insensibility and 
death in a few hours." 

c. Scarlatina of the Throat. — Dr. Tweediet has given a name 
{Scarlatina Faucium) to this variety of the disease, with which every 
practitioner must be familiar. It occurs chiefly among adults, and 
occasionally attacks those who have gone through the more regular 
form of scarlatina. It is, in fact, an appearance of the eruption in 
the mouth and throat, without any efflorescence upon the surface of 
the body. It is often attended with a good deal of fever, and may 
be followed by desquamation of the cuticle. It also appears to be 
capable of communicating an infection which will produce other 
forms of the disease. 

Pathology. — Scarlatina is subject, although perhaps not so strictly, 
to the same general laws as regulate the other eruptive fevers. It 

♦ Practical Illustrations of the Scarlet Fever. London, 1818. 
t Cyc. Pract. Med. Art. Scarlatina. 
26 



302 ERUPTIVE FEVERS. 

occurs most frequently in the earlier periods of life ; but as persons 
are not so certainly exposed to it during these periods as to measles, 
so the instances of its occurrence after puberty are more numer- 
ous than in the latter exanthem. In the circumstances of affording 
immunity against future attacks — of naturally running a definite 
course — of being, to a certain extent, spread by contagion, and of 
suspending the action of other exanthems, it is also generally ac- 
knowledged to obey the laws already enumerated. Attempts have 
been made to communicate it by inoculation, but these have not 
hitherto been successful. 

We have stated that scarlatina is, to a certain extent, spread by 
contagion ; and it is well known to practitioners, that the different 
varieties which we have described may all owe their origin, and be 
distinctly traced, to the same source of infection. Like its kindred 
diseases, however, it is unquestionably of an epidemic nature, occur- 
ring usually about the end of summer and autumn, especially in wet 
and cold seasons, and prevailing until the commencement of spring. 
From the extraordinary difference in character between the mild and 
malignant varieties, these have been supposed by some to be dis- 
tinct diseases ; but this is disproved by the fact just stated, that the 
same source of infection may produce either form. The difference 
appears to lie partly in the habit of the patient, but chiefly in the 
constitutio anni, the epidemic taking a mild character when simple 
inflammatory diseases prevail, and running into an opposite form 
when the morbid tendency is low or typhoid. Looking upon the 
subject in this way, the simple scarlatina is to be considered as the 
true type of the disease, and the malignant as something superin- 
duced; just as the simplest wound may be attacked with erysipelas, 
when it happens to be rife in the locality, or when the subject is at 
the time in an unhealthy condition. 

The post-mortem appearances in persons who die of scarlatina are 
various, according to the complications which may exist of inflamma- 
tions or congestions in the several cavities. In the malignant form 
there is every evidence of a depraved and broken-down condition of 
the blood, putrefaction occurring rapidly, and livid spots and wheals 
existing even before death. Purulent matter is also occasionally 
found in the joints, without traces of inflammation, but as if deposited 
directly from the blood. We have stated that sudden death may 
occur at an early period ; and then we may fail to discover any 
morbid characters apparently capable of causing dissolution. Dr. 
Currie* relates the case of his own daughter, in whom death was 
occasioned by ulceration of the glottis, symptoms resembling those of 
croup attending. 

Diagnosis. — The only affections with which scarlatina is likely 
to be confounded are measles and roseola. From the latter it may 
be distinguished by its regular, and longer duration, and by the pre- 
sence of the sore throat, and efflorescence within the mouth ; from 
the former by the period of appearance of the rash, by the characters 

* Med. Reports. Liverpool, 1804. 






SCAKLET FEVER. 



303 



of this, and by the sequelae — all of which have been sufficiently- 
dwelt upon. 

Prognosis. — This depends both upon the nature of the particular 
epidemic, and the condition of the individual patient. The simple 
scarlatina, though it may be attended with severe symptoms, is not 
in itself a fatal disease ; and when there is no complication of internal 
inflammation ; and the rash is of a bright red colour, comes out 
abundantly, and remains the usual time, we may hope for a favour- 
able result : but still the sequelas to which we have alluded are 
always to be dreaded, and often constitute far more formidable affec- 
tions than the primary disease. Among these, glandular swellings 
and other forms of scrofula, are most to be dreaded ; dropsy, espe- 
cially of the cavities, is also highly dangerous. 

The malignant form is always attended with great hazard, the 
favourable signs are, a plentiful, bright eruption (although even this 
may exist in very bad cases) ; florid redness in the throat, and dis- 
position of the sloughs to separate ; general scaling off of the cuticle ; 
and some degree of strength being kept up. Lividity or disappear- 
ance of the eruption, petechia?, ulcerations about the lips, spreading 
of the disease in the throat, convulsions, stupor, and general pros- 
tration of strength, are among the most unfavourable signs. The 
mortality of different epidemics varies in a most remarkable manner; 
in some, scarcely a death occurring, — and in others, whole families 
being carried off. The danger appears to be greater to adults than 
to children, and to females than to males. Of 3S fatal cases, which 
occurred in a total of 644 treated at the London Fever Hospital, 13 
were males, and 25 females.* 

Treatment, a. — In simple Scarlatina. — This must be regulated 
by the greater or lesser severity of the symptoms, the principle being 
to favour a development of the disease and prevent disturbance from 
accidental occurrences. In the mildest cases, the patient must be 
kept in bed, but not oppressed with an unusual quantity of clothes. 
The apartment should be cool and well ventilated, cooling drinks 
given freely, and abstinence from animal food and everything heat- 
in* strictly enjoined. A gentle emetic is almost always of service, 
by checking the fever and relaxing the skin, and also by clearing 
the throat of viscid mucus. Its action will be advantageously fol- 
lowed by a purgative ; but we do not go the full length with Dr. 
Armstrong, in recommending the continued use of aperients ; nor do 
we place as much reliance as he did, upon what he calls the bold 
administration of calomel. When the hepatic secretions are deranged, 
small doses of mercuryt will, unquestionably, be useful ; but we 
have long since ceased to think that calomel is a cure for febrile dis- 
eases. Currie strongly advocated the affusion with cold water, in 
inflammatory scarlatina ; and when the patient is strong and plethoric, 
with a hot skin, the weather being also warm— when, in short, 
there is no likelihood of a want of reaction, this measure will be 

* Cyclopaedia of Practical Medicine, article Scarlatina, 
f As in the pulv. rhei comp., No. 29. 



304 



ERUPTIVE FEVERS. 



attended with the best results. We can commonly, however, substi- 
tute for it sponging with cold or tepid water and vinegar; and this 
is in every case safe, and generally highly useful, bringing down the 
heat, and affording much comfort. Tepid affusion, and the warm 
bath, have also been highly spoken of, in the treatment of scarlatina ; 
but we have, ourselves, more experience of the benefits derivable 
from sponging. 

Bleeding has been recommended by some, and in certain epidemics 
(as that described by Morton), has been found advantageous. The 
weight of authority is, however, against its general employment ; 
and even by its patrons, it is recommended to be practised very cau- 
tiously. When visceral inflammation sets in during the course of 
scarlatina, and when we have the good fortune to discover it early, 
bleeding is certainly required, as it would be in ordinary fever under 
similar circumstances ; but it is only as a matter of necessity that we 
must have recourse to it ; for we believe that it is likely to prove 
injurious so far as the fever itself is concerned, delaying its regular 
course, and increasing the tendency to dangerous sequelae. If we 
are obliged to take blood, in consequence of inflammation of any 
organ, the quantity must be altogether left to the judgment of the 
practitioner ; enough should be taken to control the inflammatory 
tendency — but, if possible, not one drop more.* 

Nitre we have found to be of service in the early stages of scarla- 
tina, as a cooling and useful febrifuge. It may be given in doses of 
from one to three grains, freshly dissolved in cold water or whey. 

Gargles can seldom be used with children ; and with them, as Dr. 
Armstrong justly remarks, mild emetics will be the best gargles, 
clearing the throat, and removing the viscid secretion, which often 
furnishes a serious obstacle to respiration. In infants, the latter cir- 
cumstance requires that careful attention should be paid to the main- 
tenance of a free passage for the air, as the obstruction produced by 
viscid phlegm has been known to prove fatal. When gargles can be 
employed, the best in ordinary cases is barley water and honey, acidu- 
lated with vinegar; or half a drachm of muriatic acid to an eight- 
ounce mixture. When the fauces are covered with masses of lymph, 
or small ash-coloured sloughs, a more stimulating gargle will be use- 
ful, and an excellent one will be, a mixture of five ounces of infu- 
sion of roses, an ounce of honey, and a drachm of tincture of capsi- 
cum. The gargle recommended by Fothergili in mild cases was 
sage tea and vinegar. If we can get the patient to inhale the steam 
of hot water and vinegar, it will often afford much relief. 

When the cuticle is desquamating, at the close of the disease, 
the tepid bath will be found useful, and very comfortable to the 
patient. At this period, exposure to cold must be carefully guarded 

* For the sake of the audi alteram partem, we give the following quotation : 
"We gladly take this opportunity of asserting, from considerable experience, that 
copious bloodletting is the best remedy in severe cases of scarl. anginosa ,■ and that 
the greater the tendency to malignancy is, the more boldly must it be employed. 
This change in the treatment of scarl. maligna, has naturally followed that of its 
congener typhus," Edinb. Medical and Surgical Journal, vol. xix. p, 44S. 



SCARLET FEVER. 305 

against, and the child not let into the open air without additional 
clothing. These means, and keeping the bowels relaxed, and the 
kidneys in action, by small doses of the compound powder of jalap, we 
have found, in our own experience, the most efficient in preventing 
those dropsical effusions which form so disagreeable a sequela of 
scarlet fever. 

There is often considerable debility at the close of the disease, and 
convalescence is not unfrequently tedious, obliging us to have recourse 
to tonic medicines, as mineral acids, or quinine ; but mildly nutritious 
food will commonly be sufficient for the purpose ; and any thing in 
the way of stimulants, as wine, &c, should be given with very great 
caution, as, in the weakened state of the system, they are extremely 
likely to excite dangerous local inflammations. Dr. Armstrong 
recommends mild fresh ale, in preference to wine ; and, if any stimu- 
lant be required, it will usually answer well. 

The hair very generally falls off, after scarlatina ; and when we 
find any tendency to its doing so, it will be well to have the head 
shaved, and tepid shower baths used, as soon as the patient acquires 
strength enough to bear them. 

Any special symptom, as diarrhoea, occurring during or after 
scarlatina, must be treated according to the particular indications 
belonging to it. 

b. Treatment in Scarlatina Maligna. — When the disease exists 
under the form which we have described as the truly malignant, the 
acute stage is extremely short, and often scarcely appreciable, — 
typhoid symptoms manifesting themselves almost from the very onset. 
It is important to recollect this in the treatment, as it is only in the 
short stage of excitement that any measures of depletion are warrant- 
able. Even Dr. Armstrong, who so strenuously advocated active 
means, admits that their use, except in the early stages, would be 
inevitably fatal. What are the measures of depletion proper even for 
this stage, comes next under consideration. Fothergill,* who was the 
first accurate describerof the disease in this country, utterly discounte- 
nanced bleeding, purging, and nitrous medicines; his plan consisting of 
gentle emetics in the first instance, and subsequently aromatic cordials, 
with anodynes when diarrhoea existed ; and, as a local application, he 
recommended the mel iEgyptiacum. Huxham adopted somewhat 
of a similar plan, only, in addition to the emetic, using enemata to 
unload the bowels, and sometimes very mild laxatives, before em- 
ploying aromatics or tonics. Mineral acids, also, appear to have been 
in estimation with him. Bleeding he was decidedly opposed to, in 
the truly malignant forms ; although, carried to a small extent, he 
thought it might be useful when the disease had a more sthenic 
character. Currie styled bleeding and purging, fatal practice ; and 
also condemned his own remedy, affusion with cold water, in malig- 
nant scarlatina. Dr. Armstrong advocated bleeding, upon the theory 
that, in the first stage, the apparent debility was produced by an op- 
pression of the circulation, in consequence of a congestion of blood in 

* Works, by Lettsom. London, 1784. 
26* 



306 ERUPTIVE FEVERS. 

the venous system ; he also supposed that calomel had a special effect 
in equalizing the circulation, and accordingly he prescribed it in very 
large doses. These two measures, with active purging, and the saline 
warm bath, constituted his plan of treatment. Those, however, who 
read his Essay carefully, will easily perceive that he was not free 
from misgivings as to his practice ; and it is equally obvious, that he 
considered the mere circumstance of the disease being severe and vio- 
lent as a sufficient sanction for the use of severe and violent remedies. 
Such a notion, though popular and common, is altogether inconsistent 
with an enlarged view of disease, and justifies the apologue of 
D'Alembert, — the physician being then, truly, a blind man armed 
with a club, who, as chance directs the weight of his blow, will be 
certain of annihilating either nature or the disease. A fever being 
likely by its violence to produce speedy death, is no palliation of the 
guilt of a physician who administers a medicine in poisonous doses, 
even though he may be ingenious enough to construct a theory 
explaining, satisfactorily to himself, the secundum artem character 
of the murder he commits.* 

We are, on these accounts, as well as from the views our own 
experience has led us to adopt, obliged to differ considerably from 
many of Dr.. Armstrong's positions, although fully impressed with 
the importance of some of them, and with the general ingenuity of 
his essay, — circumstances which, of course, only call for a more 
distinct warning against the dangers into which his theories might 
lead the inexperienced. Without going at any greater length into 
the opinions of others, we shall now state briefly our own ideas as to 
the proper treatment of the disease* , 

If any thing gives a chance of cutting short a typhoid fever, we 
believe it to be the sudden shock produced upon the nervous system 
by the operation of an emetic ; and accordingly, our first step usually 
is the administration of a medicine of this nature. Where the patient 
is much excited, and no irritation of the bowels present, we prefer 
the tartarized antimony: when there is much feebleness, we usually 
employ ipecacuan ; and this drug often operates advantageously 
upon children, by freeing their bowels, after its emetic action has 
been accomplished. With respect to actual aperients, we think they 
are often required and beneficial, — the discharges being depraved 
in character, and frequently destitute of bilious matter. They should, 
however, be of a mild kind, as the manna mixture (No. 2&, p. 123) ; 
or if we desire to give a mercurial, the compound rhubarb powder 
(No. 29, p. 127). If the affection of the throat be very distressing, 
occasioning much difficulty in respiration, before the appearance of 
sloughs, we may think it advisable to put leeches to the neck, or be- 
hind the ears; and if intense headache and stupor exist at the very 
commencement, the adoption of a similar measure may be justifiable, 
upon the grounds of local congestion being presumed to exist within 
the head. This is the utmost extent to which we can ourselves con- 

* For such practitioners, we know no better advice than that of the judicious 
Huxham, — "at least to peruse the sixth commandment." 



SCARLET FEVER. 3o7 

scientiously go, in recommending depletory measures in scarlatina 
maligna : but it is right to state, that some experienced practitioners 
hope for benefit from a small bloodletting , if it can be performed at 
the very onset. When an epidemic invades a family of children, 
we may have an opportunity of trying this practice in cases arising 
during our attendance upon those earlier attacked ; but it is, at best, 
an experiment, and must be tried with great caution. Our practice, 
in addition, during the stage of excitement, is to immerse the patient 
in a warm bath, strongly impregnated with salt, as Dr. Armstrong 
directs, and subsequently to rub the skin with warm dry flannel, 
especially when irregular distribution of heat exists • when, also, 
bottles of warm water, or heated bricks, should be applied to the cold 
extremities. 

When the stage of excitement has passed, support will be required,, 
and such nourishment as the patient can take, as broths, must be given ; 
and if collapse approaches, wine and other direct stimulants will be 
demanded. By some, these latter have been much employed in the 
treatment of malignant scarlatina. Dr. Peart recommends carbonate 
of ammonia, in large doses (five or six grains, every second or third 
hour), as a sort of specific for the disease. We think, however, that 
stimulants should only be given when the patient is actually in a 
state of exhaustion, — - as, in the weakened state of the circulatory 
system, they are very likely to occasion local determinations of blood, 
of a peculiarly dangerous character. We would, therefore, be de- 
sirous of using only such tonics as are unlikely to produce a heating 
or excitant effect, and, on this account, prefer the mineral acids, with, 
small doses of sulphate of quinine. 

Local treatment should attract our principal attention in bad cases 
of scarlatina, the local disease causing much distress, and probably 
sometimes perpetuating a destructive reaction in the system. WTien 
the case is met with early, the dusky red, erysipelatous inflammation 
existing in the fauces, without ulceration or sloughing, we would 
recommend the free application of a strong solution of nitrate of 
silver (ten grains to the ounce), to all the parts concerned. It can be 
best applied by means of a piece of lint sewed to the finger of a 
leather glove, which latter is to be placed upon the forefinger of the 
operator. When sloughing or ulceration has set in, we have found 
the best applications to be the mel iEgyptiacum ; or a linctus made 
of five grains of sulphate of copper, and half an ounce of honey. If 
gargles can be used, the capsicum gargle already mentioned may be 
prescribed. Dr. A. T. Thomson recommends one composed of 12 
drachms of the chloro-sodaic solution of Labarraque to 1 vss. of water 
and 5ss. of honey. Fumigations of chlorine and other gases have 
been recommended, but are not much employed in practice. The 
application of blisters in this disease, at least to children, is, we con- 
ceive, contraindicated by the tendency to gangrene which exists, 
and which is likely to be communicated to the blistered surface. 
There is one measure, in the treatment of malignant scarlatina, of 
which we have not yet spoken, although it is probably the most im- 
portant and efficient of all. We allude to the free admission of fresh 



308 



ERUPTIVE FEVERS. 



air. In children living in crowded apartments, we have witnessed 
the most marked change in the condition of the throat to be imme- 
diately produced by free exposure to air ; and in every possible case, 
we would recommend the practice to be adopted. 

If a patient be fortunate enough to become convalescent from 
scarlatina maligna, the greatest delicacy of management is required, 
in order to prevent local congestions, or other dangerous sequelse, 
from occurring. While sufficient mild nourishment is given, a care- 
fully antiphlogistic regimen must be observed, every thing stimulant 
or heating being avoided, and gentle laxatives administered, so as to 
prevent any accumulations in the bowels. By such a plan, we shall 
also best prevent the dropsical effusion which is likely to follow the 
sthenic form of the disease. When this latter sequela has once set 
in, it requires purgatives, and sometimes bloodletting, being usually 
of an inflammatory character, as is evinced by the state of the pulse, 
skin, and secretions. Convalescence from any form of scarlatina is 
often tedious ; and the patient should never be pronounced out of 
danger, until a state of perfect health be regained. 

Prophylaxis. — Dr. Hahnemann, of Leipzig, the originator of the 
homoeopathic doctrine, has put forward the opinion that belladonna 
possesses the power of preventing the reception of the infection of 
scarlatina. His plan is to dissolve three grains of the extract of bella- 
donna in an ounce of distilled water, and give two or three drops 
twice a day to a child under a year old, and one drop more for every 
year additional, during the time of exposure to infection. His views 
have been corroborated by several German physicians ; but we 
cannot speak of the plan from any experience of our own. 



III. SMALL-POX (VARIOLA). 

This eruptive fever, though once the agent of destruction to entire 
nations, has now, thanks to the genius of Jenner ! almost ceased to 
engage the attention of physicians. Its continued existence, how- 
ever, should not be forgotten, nor any neglect of the proper precau- 
tions against its ravages be induced by security, even though that 
has been now enjoyed for nearly forty years. We shall consider the 
disease as it occurs in the mild or distinct ; the severe or confluent : 
and the modified forms. 

a. Symptoms of Distinct Small-Pox. — Natural small-pox runs 
through a regular course of three distinct stages, viz. — 1, of incu- 
bation ; 2, of maturation ; and, 3, of decline. The space of time 
between th£ reception of the infection and the first invasion of the 
febrile symptoms, although probably a definite one, has not been 
absolutely agreed upon by writers; the average period, however, 
appears to be about fourteen days. The commencement of the fever 
is commonly well marked, being for the most part a sudden and 
severe rigor, followed by excessive heat, pain in the head and back, 
nausea, pain at the pit of the stomach, weakness and giddiness, with 
disposition to heavy sleep. In children, we have observed the first 



SMALL-POX. 3og 

appreciable symptom to be a convulsive fit ; and this was considered 
by Sydenham to be a favourable sign. The symptoms just enumer- 
ated are those belonging to other eruptive or ordinary fevers, and 
can only be inferred to belong to small-pox by a knowledge of ex- 
posure to contagion. 

On the fourth day,* inclusive, from the commencement of fever, 
the second stage begins. An eruption of small, red, elevated pim- 
ples shows itself, first upon the face, and neck, and subsequently 
upon the rest of the body, being completely out in a period varying 
from twenty-four hours to two or three days. The eruption is not 
confined to the skin, being often extended to the mucous membrane 
of the mouth and throat, and sometimes to the tunica conjunctiva of 
the eye. Its appearance is usually accompanied by a considerable 
abatement of the febrile symptoms, and sometimes by profuse sweat- 
ing. The pimples quickly grow larger and higher, their increase in 
size being attended with pains in the jaws, and general redness of 
the skin. In two or three days from their first appearance, they 
become vesicular, the vesicle being formed of distinct cells, contain- 
ing a straw-coloured fluid, and depressed in the centre: their seat is 
in the true skin. 

From day to day, the redness and swelling of the skin increases, 
and is accompanied with pain ; the face becomes swollen, so that the 
eyelids are usually closed ; the hands and fingers also swell. The 
distinct cells in the vesicles gradually run together, and, losing the 
central depression, they acuminate and form pustules, filled with a 
thick, opake, yellowish matter. This process, called maturation, is 
completed about the eighth day from the commencement of the 
fever; and the pustules are then about the size of a pea; yellow, 
and in some places rough, and the intervening skin of a florid red 
colour, resembling the hue of a damask rose. On the eleventh day, 
the swelling and inflammation of the skin on the body and face de- 
cline, and the pustules upon these parts dry up, and form scabs, 
which fall off about the fourteenth or fifteenth day, leaving behind, 
in some cases, the peculiar marks of the disease — in others, merely 
discoloured spots, which soon disappear. The pustules on the hands 
remain a day or two after the others, and often break, and leave 
troublesome sores. 

b. Symptoms of Confluent Small-Pox. — These are, in the first 
stage, similar to those of the distinct form, but more severe and 
violent, the fever running higher, and being accompanied by con- 
siderable nervous excitement, often amounting to delirium. The 
eruption appears generally, upon the third day, coming out earlier 
than in the milder form; but Sydenham observes, that when the 
fever is of extraordinary violence, there may be no eruption until the 
fourth or fifth day. The febrile symptoms do not so markedly abate 
upon the commencement of the second stage, as they do in the dis- 
tinct variety, but continue with greater or lesser severity. At first, 

* This is Sydenham's account. Dr. Gregory, in the article " Small-Pox,'* Cyc. 
Pract. Med., states the duration of the fever to be forty-eight hours. 



10 



ERUPTIVE FEVERS. 



the eruption has nothing peculiar in itself; but, in a day or two, it will 
be perceived that the pustules are not rising so high, or filling so much 
as usual ; and by degrees those upon the face run into one another, 
and form one continuous bag, containing a thin sanious fluid, instead 
of pus. The face becomes considerably swollen ; and as the conflu- 
ence takes place, it loses its red colour, and becomes pallid and doughy. 
About the eighth day, the covering of the pustules changes to a 
dusky colour, or it bursts, and dark brownish fetid scabs are formed. 
In either case, the surface becomes rough ; and at length, towards 
the twentieth day, large scales fall off, disclosing ulcerations of the 
true skin, which ultimately leave permanent pits and seams. It is 
principally upon the face that the confluence of the pustules takes 
place ; and the danger of a particular case is chiefly to be inferred 
from the condition of the face, both as to the number of pustules upon 
it, and their more or less unhealthy appearance. During the course 
of confluent small-pox, children are commonly affected with diar- 
rhoea, which appears to be analogous to the salivation to which 
adults are subject during the stage of eruption. 

In the distinct form, we have stated that the fever abates consider- 
ably upon the coming out of the eruption, and does not, under ordi- 
nary circumstances, return again during the course of the disease. 
This, however, is not usually the case in the form we are now consider- 
ing — as about the tenth or eleventh day from the commencement, 
when the scabs are forming, an attack of secondary fever often sets 
in. This is attended with a variety of distressing symptoms : the 
skin becomes dry and hot, with quickened pulse, white tongue, and 
thirst ; the head is often affected at this time, violent delirium or coma 
being present, or that peculiar affection of the nervous system, re- 
sembling delirium tremens, which is occasionally observed to attend 
upon severe accidents, as burns or scalds, &c. The chest is also 
liable to be effected, especially the pleura, which is not uncommonly 
the seat of sudden and fatal inflammation. The abdomen, it is said, 
is not so commonly the seat of disease in small-pox as either of the 
other cavities. Boils and abscesses may, also, form in various parts 
of the body, and may be accompanied with glandular swellings and 
petechias, or hemorrhages from some of the passages. Gangrene of 
the genitals is not an unfrequent occurrence, and usually proves 
fatal. A. destructive ophthalmia, invading all the texture of the eye, 
and often causing sloughing of the cornea, is also a common com- 
plication. 

c. Symptoms of Modified Small-Pox. — Variola has occasionally 
occurred epidemically, in a peculiarly mild form, and has been, 
under such circumstances, described by the older authors as " stone- 
pox," " horn-pox," or " siliquose-pox." The disease, also, although 
usually obedient to the general law of the exanthemata, of occurring 
but once in the same individual, does sometimes recur ; and in about 
the same ratio of frequency, it visits those who have been protected 
by vaccination. When it recurs under these circumstances, it assumes 
the modified characters, which we shall now describe. 

The first stage of modified small-pox differs little from that of the 



SMALL-POX. 311 

natural form, the fever being often very severe, and presenting no 
peculiar characters. There is, however, considerable difference in 
the eruption, which is seldom very copious, and usually begins to 
decline about the fifth day. The fever mostly abates upon the 
appearance of the eruption, and the pocks do not advance to matu- 
rity, but dry up and become hard and horny, by the fifth day. When 
they fall off, a mottled red condition of the skin remains, and some- 
times a slight pitting continues visible for a considerable period, or 
even may be permanent. Although the pustules may sometimes be 
numerous, and even run together, becoming partially confluent, still 
the fever is seldom high after the first stage, and there are rarely 
any dangerous complications. That the disease is actually small- 
pox is, however, proved by its being the result of exposure to con- 
tagion, and also by its being capable of communicating a severe form 
of the disease by inoculation. 

Pathology. — Small-pox obeys the general laws of exanthema- 
tous diseases. It is, however, less a disease of childhood than any 
of the others, probably because it is more usually propagated by 
contagion, and possesses rather less of an epidemic nature. The 
contagious character is very well marked-, but appears to be most 
strong during the stages of maturation and decline. The type of an 
individual case does not always appear to influence the disease pro- 
duced by infection from it, in another patient, as the mildest cases 
may communicate the most severe form, and vice versa. With respect 
to the type of the disease, much variation is produced by the pecu- 
liar constitution of the patient, and also by the epidemic constitution 
of the year or season. Certain persons, but those very few in num- 
ber, appear to be altogether insusceptible of variolous infection. 

The morbid appearances observable in those who die of small- 
pox are, for the most part, those proper to complications which arise 
during the progress of the case — being inflammatory conditions of 
the brain, or respiratory organs : ulceration of the bowels is some- 
times met with ; but the abdomen is comparatively seldom the seat 
of lesion. When the disease has been peculiarly malignant, and the 
fever typhoid, marks of putrescency will be observable in the rapid 
approach of putrefaction, and the existence of livid wheals and 
petechia upon the surface of the body. The larynx and trachea 
sometimes present peculiar appearances — being covered with a 
quantity of dark-coloured, viscid secretion, and the mucous mem- 
brane being thickened and pulpy, or even in a sloughy and disor- 
ganised condition. We have already particularised, at p. 263, an 
instance of fatal ulceration of the rima glottidis supervening upon 
small-pox. 

Diagnosis. — The characters of the fever and eruption sufficiently 
distinguish small-pox. It can only be confounded with varicella, or 
chicken-pox, which is to be known by its shorter and milder course. 
The modified small-pox can, however, scarcely be distinguished from 
varicella, and is by some considered to be identical with it. 

Prognosis. — This must be entirely regulated by the form of the 
disease, and by the absence or presence 1 , and character of complica- 



312 



ERUPTIVE FEVERS. 



tions. Confluence of the pustules is always a sign of danger ; as is 
also a large number of pustules upon the face, and there remaining 
flat and pale, instead of filling well, and being surrounded with a 
bright red areola. Hoarseness, or croupy cough, is unfavourable, as 
indicating an affection of the larynx. The state of the system must 
be taken into account, and also the age. Healthy persons, neither 
very plethoric nor delicate, will escape best ; while infants and very 
young children are more liable to suffer complications than those of 
a more advanced age. Any evidences of a debilitated system, as 
petechia?, hemorrhage, gangrene, &c, are very unfavourable signs. 
Certain periods of the disease appear to be particularly critical : these 
are stated by Sydenham to be, in the distinct form, the eighth, and 
in the confluent the eleventh days, from the commencement of the 
fever. In making a prognosis, even in mild cases of small-pox, we 
must recollect the liability to dangerous sequelae which always exists ; 
various forms of scrofula, and severe ophthalmia, for example, being 
likely to follow attacks apparently very favourable in their primary 
states. The average mortality of small-pox may be stated at about 
one-fourth of those who are attacked ; and when we reflect upon the 
small probability of any individual escaping from the frequent epi- 
demics which raged before the happy recovery of Jenner, we must 
be led to form a frightful estimate of the destroying power of this for- 
midable disease. 

Treatment. — The principle upon which the treatment of every 
form of small-pox should be conducted is, in a word, the prevention 
of any circumstance which may be likely to disturb or interrupt its 
natural course. Any steps, on the one hand, which may heighten 
the fever, as a hot regimen and apartment ; or which, on the other, 
may diminish the strength to the degree of causing debility, as inor- 
dinate evacuations, — will produce such disturbing effect, and should 
be carefully avoided. The happy medium desirable to be attained 
is the restraining of the fever, so as to prevent the occurrence of local 
congestions or inflammations, and at the same time to leave a suffi- 
cient degree of strength to enable the patient to pass through what 
may be a tedious and debilitating disease. 

To furnish rules for the attainment of these objects, we cannot do 
better than give the substance of Sydenham's plan of treatment, 
which has never been improved upon, and which, if we consider the 
state of opinion existing at the time of its promulgation, may be 
safely recommended to the student as a model of the observation, 
reasoning, and practice of a true physician. 

"As soon," says Sydenham, "as" the signs of this disease show 
themselves, I keep the sick from the open air, and forbid them the 
use of wine and flesh, and allow them small beer gently warmed, 
with a toast, for their ordinary drink, and now and then I permit 
them to drink as much of it as they will. I order them, for their 
victuals, oatmeal and barley broth, and roasted apples, and other 
things, which are neither too hot nor too cold, nor of too hard a 
digestion. I forthwith prohibit a hotter regimen, and the use of all 
manner of cordial medicines, * * * for I have more than once ob- 



SMALL-POX. 3 13 

served, in young people of a sanguine complexion, that a hot regimen 
and cordials given on purpose to force out the small-pox before the 
due time, have so little promoted their coming out, that, on the con- 
trary, they have given a check to it * * * till at length, by allowing 
small beer, and taking off part of the load of clothes wherewith he 
was roasted, I have made a convenient way for the pustules to go 
out ; and so I have put the patient out of danger, by God's assist- 
ance.'' He also discountenanced confinement of the patient to bed 
in mild cases before the fourth day : " for bloody urine, purple spots, 
and other mortal symptoms, come upon people merely because they 
are too soon confined to their beds." After the fourth day, he recom- 
mended opiates at bedtime, for the purpose of allaying irritation ; and 
their employment is sanctioned by our knowledge of the benefit often 
derived from them in the treatment of that low form of delirium at- 
tendant upon burns and scalds, — a state, similar to which, so fre- 
quently accompanies small-pox. In addition to this treatment, should 
there be no diarrhoea present, it will be advisable to free the bowels 
gently by injections or mild aperients, as the manna mixture (No. 25, 
p. 123), or the powder of rhubarb and magnesia (No. 27, p. 126). 
Sydenham was not solicitous about restraining the diarrhoea which 
sometimes attends, considering it to be critical. 

When the fever ran high in plethoric persons, Sydenham recom- 
mended bloodletting : with children this measure is not so frequently 
called for ; but if we meet with very high febrile symptoms, and 
especially if any tendency be evinced to local imflammation in the 
head or chest, we must draw sufficient blood, either from the arm or 
by leeches, to moderate those symptoms. Our dread of subsequent 
debility must always be moderated by the recollection that over- 
action, which is particularly liable to occur in this disease, frequently 
produces prostration of strength, and that the reduction of such over- 
action in time, may be the most efficient means of husbanding the 
patient's powers. It is, however, not to be forgotten that the ex- 
tensive suppuration, which ought to take place in the maturation of 
the pustules, requires that the strength should not be wantonly 
taxed. 

In the distinct form, after the coming out of the pustules, Syden- 
ham continued the same antiphlogistic regimen, but allowed the 
patient to rise from bed for a few hours every day, unless the weather 
was cold, or there was a large eruption, when he kept the patient 
continually in bed, but with no more clothes upon him than when 
he was in health, so as to avoid, if possible, the production of per- 
spiration. 

When the disease is going off, mildly nutritious food may be given; 
and if there be restlessness, an occasional anodyne ; but stimulants 
are not often required, and must always be resorted to with extreme 
caution. The state of the bowels should be watched throughout 
this stage, and mild laxatives administered, when necessary. 

When the disease is confluent, greater care is required in the com- 
mencement, to prevent the fever from attaining a dangerous height ; 
but the principles of treatment are identical with those which we 
21 



314 ERUPTIVE FEVERS. 

have just laid down. When the secondary fever has set in, it must 
be met by diluent drinks, occasional aperients, and, if there be irri- 
tation and restlessness, opiates ; — bleeding is seldom safe at this late 
period. Among children, Sydenham justly remarks, opiates are not 
so often advisable, as they would tend to stop the diarrhoea, which 
is not to be unnecessarily interfered with, being, in fact, a sort of 
critical evacuation. In bad cases, the access of secondary fever is 
sometimes quickly followed by extreme debility, coldness of the ex- 
tremities, petechiae, and, in short, the whole train of typhoid symp- 
toms. A similar state is sometimes produced by the drain of matter 
from the pustules, when these are very numerous ; and sloughing 
sores upon parts of the body exposed to pressure, may also attend. 
Under these circumstances, wine, tonics, and stimulants are called 
for, and furnish the only means of supporting the patient's strength. 
The pustules do not require any particular local treatment ; they 
should be left to themselves, except so far as anointing them with a 
little cold cream, or oil of almonds, when they become hard — or 
dusting over the surface with starch, or other dry powder, when 
they are discharging thin, sanious matter. The hands of children 
should be muffled, to prevent them from breaking the pustules upon 
their faces, which the extreme itching would otherwise lead them to 
do. The hair of the head, also, should be clipped, as otherwise it is 
apt to become matted with the discharge, and then to occasion great 
irritation and pain. 

The different complications and sequelae must be treated upon 
ordinary principles ; but it is particularly necessary to guard against 
the effects of ophthalmia. When this inflammation occurs it must 
be promptly checked by the application of leeches, or such other 
remedies as may be required, otherwise there will be considerable 
risk of destruction of sight. There is nothing particular to be said 
upon the treatment of modified small-pox : the principles of its 
management are similar to those already laid down. 

Inoculation for Small-Pox. — It would be exceeding our limits 
to go at any length into a consideration of this subject, as it is now 
happily superseded by vaccination. The practice was first intro- 
duced into Great Britain from Turkey by Lady Mary Wortley Mon- 
tague, and was found materially to diminish the perils of small-pox. 
It has since been discountenanced by judicial decisions,* in conse- 
quence of the equal security afforded by vaccine inoculation, and the 
additional advantage possessed by the latter measure in not consti- 
tuting artificial fomites of variolous infection. 

The mode of inoculating is similar to that of vaccinating, which 
shall be treated of at length. The manner in which the disease 
runs its course, when introduced in this way into the system, is as 
follows : 

* The King v. Burnet, and the King v. Vantandillo. 4 Maule and Selwyn, 
pp. 271-73. 

More recently the production of small-pox, by inoculation or wilful exposure to 
infection has been made punishable with one month's imprisonment, by the 3d and 
4th Vic. c. 29. s. 8. [Note to 4th Edition.] 



CHICKEN OR SWINE-POX. 3l - 

On the third day after inoculation, the wounds show some slight 
marks of irritation, and a minute pimple is perceptible. On the 
fourth day, this is converted into a vesicle with a depressed centre, 
and the patient begins to feel an itching and slight uneasiness in the 
part, which upon the sixth day is increased to pain and stiffness, 
extending towards the nearest lymphatic glands. About the seventh 
or eighth day, rigors and other febrile symptoms, as nausea, head- 
ache, pain in the back, &c, occur, and in the course of forty-eight 
hours afterwards, the eruption appears. The number of pustules is 
generally very limited, and they usually run their course precisely 
in the same manner as the natural, distinct pox. In some cases, 
however, the result is not so favourable, death occasionally occur- 
ring 5 — shortly after the introduction of inoculation into Great 
Britain, and its adoption with two of the Princesses of the blood, the 
practice did actually receive a check in consequence of its producing 
fatal results in three remarkable instances. 

We have introduced a notice of the subject here, on account of its 
weight as a pathological phenomenon ; but as matters stand at pre- 
sent, it is the unquestionable duty of every practitioner to discourage 
the practice of variolous inoculation, both as being opposed to the 
spirit of the law, and as being a measure hazardous to the commu- 
nity, by keeping alive the infection of a most baleful disease. For a 
full consideration, however, of all the bearings of the question, we 
must refer to our chapter on Vaccination. 

IV. CHICKEN OR SWINE-POX "( VARICELLA). 

This mild exanthem may be said to be peculiar to the period of 
childhood, as it very rarely affects adults. It has been divided by 
authors into four varieties — viz., V. Lentiformis vel Lymphatica, 
V. Coniformis, V. Globularis, V. Corymbosa : the division is based 
upon the varying characters of the eruption, but is of no practical 
importance. 

Symptoms. — We have always observed the eruption of chicken- 
pox to be preceded by more or less fever ; the patient usually under- 
going a rigor, succeeded by the ordinary febrile symptoms, for a day 
or two before the appearance of the rash. Such is also the opinion 
of Dr. Willan* and of Dr. Copland,! although it is asserted by some 
writers that febrile symptoms are unusual. 

The eruption first appears upon the back, neck, and breast, the 
face being comparatively free. It very early (indeed, usually from 
the very commencement,) assumes a vesicular character, coming out 
suddenly in form of little blisters, about the size of split peas, and 
rilled with a transparent, straw-coloured, or yellow lymph. These 
vesicles may be lenticular, conoidal,or globular, or may run together 
in clusters, thus constituting the four varieties. If they happen to 
be punctured, or are broken, the fluid is discharged, and the cuticle 

* On Vaccine Inoculation. 

f Dictionary of Practical Medicine. 



316 



VACCINATION. 



falls evenly on the cutis, there being no elevation or hardness in the 
latter tissue. Successive crops of vesicles come out, which is cha- 
racteristic of the disease, not occurring in any of the other eruptive 
fevers. There is usually a slight degree of redness of the skin around 
the vesicles ; and they are commonly accompanied with itching, 
which mostly causes them to be broken early. About the fourth or 
fifth day, they begin to dry up, being converted into brown, gummy 
scabs. These crumble off in the course of a week or ten days, some- 
times leaving slight pits, but more generally, mere discolorations of 
the skin. 

Pathology. — Chicken-pox obeys the general laws of the exanthe- 
mata : its contagious nature, however, is not so clearly made out as 
that of the others, as it has not been satisfactorily proved that it can 
be communicated by inoculation. It has been supposed by some to 
be merely a mild variety of small-pox ; and this question, which is a 
curious and interesting one, shall be discussed in the chapter on 
Vaccination/ 

Diagnosis. — Chicken-pox is to be distinguished from small-pox 
(supposing it not to be a modified form of that disease), by its mild- 
ness ; by the rash early assuming a vesicular character, the vesicles 
not being depressed in the centre, and coming out in successive crops. 
It must be confessed, however, that it is not easy to discriminate it 
from some forms of modified small-pox. 

Prognosis. — This is always favourable, — no danger existing 
except from accidental complications. 

Treatment. — Very little is required, it being merely necessary to 
keep the child in bed for two or three days, and to prohibit animal 
food or heating drinks. Towards the close, a mild laxative may be 
given, and the return to ordinary food and habits gradually effected. 



CHAPTER XII. 

VACCINATION.* 

Edward Jenner, of Berkeley, to whom mankind is indebted for 
a knowledge of the great blessing of vaccination, became acquainted 
(in consequence of his residence among the dairies of Gloucester- 
shire), at a very early period of his life, with traditionary accounts 
of the security afforded against small-pox, by the casual introduction 
into the system, of a disease occasionally prevalent among the cows 
in that county. The description of the original disease will proba- 
bly be best given in his own words. 

" It has obtained," he says, " the name of cow-pox. It appears 
on the nipples of the cows, in the form of irregular pustules. At 

* The matter of this chapter is now republished from a paper by Dr. MaunseU, 
in the 4th volume of the Dublin Medical Journal. 



VACCINATION. 317 

their first appearance they are commonly of a palish blue, or rather 
of a colour somewhat approaching to livid, and are surrounded by 
an inflammation. These pustules, unless a timely remedy be applied 
frequently degenerate into phagedenic ulcers, which prove extremely 
troublesome. The animals become indisposed, and the secretion of 
milk is much lessened."* From these pustules, infection is soon 
communicated to the hands of the milker. Inflamed spots appear 
about the joints and extremities of the fingers ; these assume the 
form of circular vesicles, with elevated edges and depressed centres, 
and of a " colour distantly approaching to blue." From the irrita- 
tion and friction to which the vesicles are usually exposed, they most 
commonly ulcerate, and often pass into phagedenic sores. When 
this is the case and the points of infection are numerous, considerable 
fever and disturbance are excited in the constitution. The axillary 
glands become inflamed, and there is headache, quick pulse, rigors, 
&c. Reasoning from a great number of individual instances which 
fell under his notice, and from the general opinion of the country, 
Dr. Jenner came to the conclusion that persons affected in the man- 
ner described, became insusceptible of the infection of small-pox. 
In a happy hour the idea struck him that it might be possible to ex- 
tend the protection, by the artificial communication of the disease 
from one individual to another ; and accordingly, on the 14th of 
May, 1796, he made the first vaccine inoculation. The subject was 
a boy named James Phipps ; and the matter was procured from a 
sore on the hand of Sarah Nelmes, a dairy-maid, who had been 
infected casually in the course of her occupation. On the 1st of 
July following, the experiment was tested by inoculating the boy 
with variolous matter, taken directly from a pustule. This was 
again repeated, after some months, " but no sensible effect produced 
on the constitution." Similar experiments were tried upon others; 
and in June, 1798, Jenner published his first work upon the subject. 
His hypothesis at this period was, that cow-pox and small-pox were 
modifications of the same disease, and that the origin of both was to 
be found in the cutaneous inflammation to which horses are subject, 
and which, when it affects their heels, is termed grease. He con- 
ceived, however, that although a disease resembling cow-pox might 
be communicated to a human subject directly from the horse, still it 
failed to afford protection unless it has intermediately passed through 
the system of the cow. In every instance he thought the disease in 
the cow could be traced to infection, either from another animal of the 
same species, or from the matter of grease, communicated by the 
hands of a milker. By after observations it has been ascertained that 
the grease, at its commencement, and before its characteristics have 
been destroyed by friction, is a vesicular eruption, very similar in 
appearance to that which occurs upon the nipples of the cow. It is 
also stated that Mr. Gardner succeeded in producing the vaccine 
disease in the cow by a direct inoculation from the eruption in ques- 
tion ; and that Dr. Loy, and Dr. Sacco of Milan, were able to pro- 

* Inquiry, &c, 3d Ed. p. 4. 

27* 



318 VACCINATION. 

duce it, from the same source, directly in the human subject.* In 
Jenner's " Inquiry," and indeed generally in the early stages of the 
investigation of cow-pox, we find the term pustule applied to cha- 
racterize its form. The disease, however, is strictly vesicular,t but 
the mistake was owing to the peculiar circumstances under which it 
was usually observed in the cow ; its situation, upon the nipple, 
never allowing it to run its course uninterruptedly, and the natural 
inflammation being usually much increased by friction. When the 
infection was communicated casually to the human subject, a similar 
interference with its progress almost invariably occurred, and in the 
first cases of inoculation was not sufficiently guarded against. On this 
account a very considerable febrile disturbance was frequently ex- 
cited in the system ; not by " the first action of the virus," but by 
the subsequent existence of corroding ulcers, and this indisposition 
was erroneously considered necessary to the success of the inocula- 
tion. Another error consequent on the supposition of the pustular 
origin of the eruption was the employment of purulent matter or 
ichor from an ulcer, for the propagation of the disease. The saga- 
city of Jenner, at a later period, discovered both these mistakes : he 
continued, however, to the last, to apply the term pustule, and has 
not in any part of his works given a very satisfactory account of the 
appearances and progress of the complaint, so that it was some time 
after the discovery before its exact characters were ascertained and 
recorded. In describing these, we shall avail ourselves freely of the 
descriptions given in the papers of the National Vaccine Board, and 
of those contained in Dr. Labatt's excellent Address to the Medical 
Practitioners of Ireland. 

About the third or fourth day after vaccination, a small red pimple 
is formed on the site of the operation. This is hard to the touch, 
and slightly elevated : if it be examined through a magnifier, a slight 
efflorescence will be seen to surround it, and sometimes a minute 
vesicle will be discovered on its apex. The tumour gradually 
enlarges, and about the fifth or sixth day the vesicle becomes appa- 
rent to the eye. It is circular in its form, elevated at the edges, but 
with a depressed centre ; and when at its greatest size, is sometimes 
indented by one or two concentric furrows, resembling, to use the 
simile of Mr. Bryce, a worm coiled under the skin. It goes on 
increasing in size until the tenth or eleventh day, when it is usu- 
ally about four lines in diameter. The size, however, varies accord- 
ing to the mode of inoculation ; if it has been performed by puncture, 
it is generally small ; whereas, when several scratches have been 
made, two or three vesicles frequently form, and subsequently run 
together. The colour of the vesicles is at first a light pink ; some- 
times with a bluish shade, which gradually changes to a pearl colour. 

* Life of Jenner, by Dr. Baron. 

t It may be well to keep in our minds the strict definitions of these two forms 
of cutaneous eruption : — Vesicle : a small orbicular elevation of the cuticle, con- 
taining lymph, which is sometimes clear and colourless, but often opake and whitish, 
or pearl-coloured. Pustule : an elevation of the cuticle, with an inflamed base, 
containing pus." — Willan. 



VACCINATION. 319 

The centre is darker than the margin, which is firm, turgid, and 
shining. Internally, the vesicle consists of numerous little cells, filled 
with clear transparent lymph, and, according to Dr. Willan, commu- 
nicating with each other. We should think, however, from the 
difficulty experienced in evacuating the lymph, that the communication 
is at all eventsnot very free. The quantity of virus varies considerably 
in different vesicles, and will usually be found to possess activity in 
an inverse proportion with its quantity. Dr. Joseph Clarke suggested 
to Dr. Labatt, that this might probablv be accounted for by suppos- 
ing the increased quantity of fluid to depend, not upon an increase 
of the specific virus, but upon a discharge of serum excited by the 
mechanical irritation of the part. On the eighth or ninth day there 
is formed round the base of the vesicle an inflamed ring, which spreads 
rapidly, and about the tenth day forms an areola of an inch and a 
half or two inches in diameter. This areola is intensely red, and is 
accompanied with some degree of tumefaction and hardness. The 
redness continues for a day or two, and then begins to fade, gener- 
ally from the centre to the circumference, sometimes forming two or 
three concentric rings. After the tenth day, the vesicle begins to 
decline ; the centre first turns brown, and the whole gradually 
changes into a hard, smooth crust, of a dark mahogany colour, having, 
like the vesicle, a concave surface. About the twentieth day, the 
crust falls off, leaving a permanent circular cicatrix, a little depressed, 
and marked with small pits, probably equal in number with the 
cells of which the vesicle had been composed. 

The vesicle in very young children sometimes appears a little 
earlier than has been described ; more frequently, however, the de- 
viation is to a later period. In some instances we have known it 
to remain dormant for ten or twelve days ; in others, Dr. Labatt has 
observed it bearing the characters of an ordinary phlegmon until the 
eighth, tenth, or twelfth day, when it assumed the regular vesicular 
appearance. In all these cases, if the subsequent stages be regular, 
slight deviations as to time are of no moment. 

The progress of cow-pox is sometimes suspended by the interven- 
tion of other diseases, and after their removal, proceeds regularly 
with its usual marks. Dr. Jenner relates two cases in which the vesi- 
cles advanced to maturity, during the existence, in one instance, of 
scarlatina, and in the other of measles : the areola, however, did 
not appear until these diseases had subsided. When the vesicle has 
advanced through all its stages, to the formation of the hard crust, 
local irritation will sometimes occasion the formation of pus ; this, 
however, is by no means to be regarded as a regular part of the 
process, and may usually be prevented by preserving the part from 
injury. During the early period of the history of vaccination, con- 
siderable stress was (as has been already observed) laid upon the 
constitutional affection. Since, however, the nature of the disease 
has been more perfectly ascertained, and more attention paid to the 
preservation of the vesicle from injury, it has been found that the 
general symptoms are usually very slight, often scarcely perceptible. 
They commonly occur from the seventh to the eleventh day, and 



320 VACCINATION. 

consist in restlessness, slight shiverings, followed by heat, with 
thirst and headache. In infants there is, occasionally, sickness and 
vomiting, and the child is peevish, or drowsy and oppressed. Erup- 
tions are not usual concomitants of vaccination ; but frequently, in 
children, a slight form of strophulus will be observed. As the sym- 
pathies of the skin are so active in these subjects, it is of course not 
easy to determine whether the rash be a consequence of the infection, 
or an accidental occurrence. 

One of Dr. Jenner's main positions was, that a constitutional as 
well as a local affection should follow the inoculation of cow-pox, in 
order to insure to the patient the full amount of protection. From the 
extreme slightness of the febrile symptoms, it is often impossible to 
declare, upon their evidence, that any constitutional disease has been 
felt, and it therefore becomes a desideratum to have some sure test of 
the general affection of the system. According to the instructions of 
the Vaccine Board, we may be satisfied that this has taken place, 
" when the progress of the vaccine vesicles has been regular and 
complete ;" and this is, no doubt, prima facie evidence to that effect. 
In the following case, however, which occurred under our own eyes, 
the local disease was so regular, although not absolutely complete, 
in its progress, as to appear to us to furnish grounds for doubting 
the invariable correctness of this conclusion. A child, four months 
old, was vaccinated, and had two well-formed and perfectly regular 
vesicles ; from one of which, on the eighth day, six other children 
were infected. On the ninth day the child was very feverish, and 
on the tenth, small-pox pustules appeared. These ran their regular 
course, maturating about the ninth or tenth day from their appear- 
ance, and having the characteristic depression of centre. The six 
children inoculated from the vaccine vesicle, had the vaccine disease 
perfectly and favourably. In this case, as the small-pox was not 
modified, we should be disposed to infer, that the constitution was 
not affected by the vaccination, although the vesicles were sufficiently 
mature to afford virus capable of exciting a perfect disease in six 
other individuals. An analogous case is related by Mr. Dawson, in 
the Transactions of the College of Physicians, London, vol. hi., 
p. 385, in which, small-pox pustules upon two children furnished 
matter for the successful inoculation of nineteen persons, although 
the children themselves suffered no fever, nor general eruption "of 
pustules, and in a few days afterwards, upon a second inoculation, 
took the disease regularly. Instances of local small-pox pustules 
without fever, occurring in persons much exposed to infection, but 
who have had variola before, may be found in the works of Huxham 
and many others, and these have been sometimes found to be capable 
of communicating the disease by inoculation. Notwithstanding, 
however, " these loops to hang a doubt upon" in individual in- 
stances, we are strongly inclined to think, that there is a fair pre- 
sumption of the constitution having been properly affected, whenever 
the local disease has gone through the regular course exactly as it 
has been described above, with perfect areola, cicatrix, &c. 

At the commencement of the vaccine inquiry, small-pox inocula- 



VACCINATION. g 

lation was employed as the criterion of a constitutional infection of 
cow-pox ; at present it is fortunately difficult to procure variolous 
matter for the trial, and even were it always at hand, the risk of dis- 
seminating contagion would render its use unjustifiable. When any 
shadow of doubt exists as to the efficacy of a vaccination, we should 
of course, always repeat the operation ; but it is not to be expected' 
that in every successful case, the constitution will be insusceptible of 
a re-vaccination. Very frequently, the secondary insertion of virus 
will be followed either by an erysipelatous inflammation of the arm, 
or by an irregular vesicle, quickly running to a termination, and 
generally without an areola or permanent cicatrix. Jenner, how- 
ever, has observed and recorded cases, in which both casual and 
inoculated cow-pox occurred twice and even thrice in the same in- 
dividual :* it was also his opinion, that vaccination occasionally 
took effect perfectly, after small-pox. From these facts it is plain, 
that re-vaccination cannot completely satisfy us as to the success or 
failure of the first operation : the local disease may appear a second 
or third time, or perhaps much oftener, with its characters so well 
marked, as to furnish, at each repetition, only an additional source 
of doubt. 

Owing, however, to the ingenuity of Mr. Bryce, we have a test 
of the constitutional affection, the validity of which, when it is pro- 
perly executed, has not, we think, yet been successfully impeached. 
Reasoning analogically from some experiments upon the inoculation 
of small-pox, Mr. Bryce was induced to make similar trials with 
vaccine matter, and found " that if, during the regular progress of 
cow-pox, a second inoculation be performed, about the end of the 
fifth, or beginning of the sixth day after the first, (i. e., between 
thirty-six and forty-eight hours before the areola of the first begins 
to appear,) the affection produced by this second inoculation, will 
be accelerated in its progress, so as to arrive at maturity, and again 
fade at nearly the same time as the affection arising from the first 
inoculation ; and that this will take place, although the constitutional 
affection be so slight as otherwise to pass unnoticed. " If we take 
matter, for example, on the fifth day after a successful vaccination, 
and insert it into the opposite arm, this second operation will be fol- 
lowed by a minute vesicle on the third or fourth day, being the 
eighth or ninth from the date of the first, and will be immediately 
afterwards surrounded with an areola, becoming, on the fifth day of 
its own existence, an exact miniature of the first upon its tenth day : 
both will have finished their course at the same period, that being 
usually the thirteenth day from the first inoculation, and eighth from 
the second. The rationale of the acceleration which thus takes 
place in the progress of the second vesicle, may be explained in a 

* We had an opportunity lately, through the kindness of Dr. S. Cusack, of seeing 
a family of four children, who had been vaccinated at the Cow-pox Institution of 
this city, and subsequently re-vaccinated by Dr. C. In one of them the operation 
entirely failed ; in two, one of whom was a girl of fifteen, irregular vesicles were 
excited ; and in the fourth, a child three years old, a perfect disease with an areola 
followed. In all the children the cicatrices were perfect. 



322 



VACCINATION. 



few words : the phenomena of the ordinary cow-pox before the 
eighth day, or in other words until the appearance of the areola, are 
strictly local ; when this appears, we may look upon it as a visible 
sign of the specific fever (or perhaps we should rather say action), 
being in operation in the system, and as a consequence of this general 
action, we find that a specific areola appears around any local vesi- 
cle of the same disease that may at the time actually exist upon the 
surface of the body, although that disease may not be in existence 
sufficiently long, according to the known laws of the disease, to be 
itself the cause of this phenomenon. The proper time for putting 
this test in practice, has been mentioned to be from thirty-six to 
forty-eight hours before the appearance of the first areola ;* this is 
the latest period at which we can expect it to succeed, " as it is 
necessary that the secondary affection may have proceeded some 
length, and that a small vesicle containing virus may have been 
formed by it, before the constitutional action from the first inocula- 
tion begins, otherwise no areola, but merely a slight degree of hard- 
ness will take place from the second puncture. "t We defer it to the 
latest period, in order to afford the strongest possible contrast be- 
tween the progress of the two inoculations. In estimating the value 
of this test, it is to be recollected, that from unskilfulness in the per- 
formance of the operation, or from some other accidental cause, the 
second vaccination may not take effect at all ; with common care, 
however, this is unlikely to happen, as, by taking the virus from the 
first vesicle, we are sure of its being in the very best state for com- 
municating the disease. Upon the whole, we think it is a plan 
which should, if possible, always be adopted, at least in private 
practice ; for we are aware, that in this country it would be very 
difficult to procure in public institutions a sufficient number of at- 
tendances on the part of each patient, to enable us to carry it pro- 
perly into effect. 

Having considered the disease as it exists, in its most perfect state, 
it will now be well, before entering upon the much disputed subject 
of its value, to attend to the modes adopted for its artificial propa- 
gation, and the circumstances requiring attention during the process. 
First, then, as to the age and condition of the person to be vacci- 
nated ; it is agreed by all writers that the most favourable time for 
communicating the disease to an infant is between the ages of six 
weeks and two months, which, as Mr. Marshall % observes, "is prior 
to the irritation of teething," and is also subsequent to the extreme 
irritability of first infancy. Should circumstances require it, however, 
there is little risk in vaccinating a child immediately after its birth, 
as has been repeatedly done with safety and advantage when small- 
pox was near, and sometimes even when the mother was suffering 
under that disease. 

It is very desirable that no fever, specific or otherwise, should exist 

* This, in ordinary cases, will be on the sixth day, but where the first vesicle 
has been slow, we must, of course, defer the second operation, 
f Bryce, 2d ed. p. 189. 
% Popular Summary of Vaccination. 



VACCINATION. 323 

in the system at the time of vaccinating, and also that the surface of 
the body should be free from eruptions, as in either case the local 
disease will probably be imperfect, and the constitutional affection 
be very likely to be suspended, or perhaps altogether prevented. It 
has been observed, however, both by Jenner and Bryce, that chronic 
eruptions are sometimes benefited by the introduction of the vaccine 
disease ; and their existence is not sufficient to prevent us from vac- 
cinating, although it would certainly be calculated to make us more 
suspicious of the case, and ought to induce us to repeat the operation 
upon a future occasion. 

The probability of exposure to small-pox contagion would of course 
make us more anxious to anticipate it, if possible, by a milder dis- 
ease ; and indeed we are not aware of any other conditions than 
those alluded to, either of the body or season, that could make us 
hesitate about submitting an individual to vaccination. 

A most important point in the conduct of vaccine inoculation is 
the employment of active virus, which we can of course only pro- 
cure from perfect specimens of the local disease. In the early periods 
of the practice, much confusion and disappointment arose from an 
imperfect. understanding of the stages of the affection; and some 
mischief was done before Jenner discovered the necessity of always 
employing matter in a limpid state. Later observers all pretty well 
agree in recommending the virus to be taken, not merely when in a 
limpid state, but before the areola has begun to form ; and accordingly, 
the vesicles are now almost universally opened for infection on the 
eighth day. If the progress of a vesicle be slow, but at the same time 
regular in other respects, we may safely employ matter taken a day 
or two later, provided the areola has not appeared. 

Having selected a vesicle at the proper period, we make, with the 
point of a lancet, three or four slight punctures in its elevated margin, 
from which minute drops of transparent lymph will soon be observed 
to exude. This may be either taken upon the lancet, and at once 
inserted into the skin of another individual, or may be collected and 
preserved for future use.* In the preservation considerable attention 
is required, in order to prevent a destruction of the specific proper- 
ties of the virus, either by decomposition, or by exposure to the ac- 
tion of the atmosphere. To effect these purposes, various contri- 
vances have been devised ; one of the best is, to receive the lymph 
upon a small square of glass, allow it to dry, and then, covering it 
with a similar piece of glass, fold both up in a portion of moistened 
bladder or gold-beaters' skin. For more immediate use, it may be 
taken upon thin pointed blades of quill or ivory; these should be 
charged with lymph two or three times, being allowed to dry between 
each charging, and then enclosed into a packet with gold-beaters' 
skin. When it has been desired to keep the virus for a considerable 
length of time, it has been allowed to ascend from the punctured 
vesicle into glass capillary tubes, or into glass tubes with bulbs, the 

* If it be not convenient to employ the virus immediately, we may keep it on the 
lancet, but only for a few hours, as the latter very soon rusts. 



324 



VACCINATION. 



air having been rarified in the latter by the application of a lighted 
taper : in either case, the tubes are to be hermetically sealed imme- 
diately on their being charged with matter. Mr, Bryce ascertained, 
that although the fluid found in the vesicle after the formation of the 
areola seldom produced a perfect disease, still the dry crust of a ma- 
ture cow-pock always succeeded. He explained this apparent ano- 
maly by inferring that the crust is actually the limpid virus in a con- 
centrated state ; and that the fluid occasionally found in the vesicle, 
after the crust has begun to form, is merely the product of irritation, 
and not specific. At all events, a solution of the crust is found to 
produce a true cow-pock ; and by keeping it dry in a well-stopped 
phial, its activity can be preserved to a very extended period. 

We may now consider the manner of communicating the infection, 
which, in every possible instance, should be done with liquid virus 
taken directly from a vesicle. The best site for the operation is over 
the insertion of the deltoid muscle, as being the part of the arm least 
likely to be disturbed by muscular action. It may be performed 
either by scratch or puncture ; the last by stretching the skin, and 
introducing the point of the charged lancet obliquely between the 
cuticle and cutis, keeping it in the wound for a few seconds, and then 
wiping it repeatedly over the puncture. In the insertion by scratch, 
which we think much preferable to the other, and which, when well 
done with fresh lymph, scarcely ever fails, a very blunt, but clean lancet, 
answers best : this should be charged with virus in the manner already 
described, and its edge then drawn repeatedly, but very lightly, over 
the cuticle, so as to make five or six scratches, each about the eighth 
of an inch in length. Upon these the lancet should be rubbed until 
the lymph has been completely wiped from its point. When done 
properly, no blood should flow from these scratches ; they should 
merely become red, like those accidentally made with the point of a 
pin. They require no application ; and by exposure for a few 
minutes to the air, the small quantity of serum which exudes from 
them becomes hardened into a thin scab. At least two points of 
insertion should always be made, and by some it is recommended to 
make two in each arm. This, however, is unnecessary, unless we 
require a large stock of infection ; and the chances of the vesicles 
being preserved entire, will be much diminished by the attention of 
the nurse being divided between both arms. At all events, one 
vesicle should always be allowed to run its course entire ; and when 
only one point of inoculation has succeeded, that should not be 
punctured for the supply of virus. According to the hypothesis 
already stated, of the disease being strictly local at its commence- 
ment, we may conceive it possible to prevent the constitutional affec- 
tion by removing the lymph, on the absorption of which its excite- 
ment is altogether dependent. 

When, instead of the recent infection, we have to employ that 
which has been preserved dry upon glass, we must take upon the 
point of a lancet the smallest possible portion of cold water, (a very 
low degree of heat with moisture is sufficient to decompose the 
virus,) and rub it on the lymph until the latter is completely dis- 



VACCINATION. 32 5 

solved. The solution is then to be collected on the lancet, and used 
precisely as the recent matter. 

When employing points of ivory, or other material, we must first 
make a slight oblique puncture with a lancet, and into it insert the 
point, which is to be allowed to remain for a minute or two, and then 
to be wiped frequently over the puncture. 

When capillary or other tubes are used, the matter must be 
expelled from the broken tube with a blow-pipe, and then inserted 
in the same manner as if it were recent. Crusts, as recommended 
by Mr. Bryce, are prepared for use by solution in a drop or two of 
cold water. Lancets employed in the operation, it is scarcely neces- 
sary to say, should De kept perfectly clean and free from rust, as they 
might otherwise produce sores which would materially interfere with 
the disease we wish to establish. In performing the operation, the 
great cause of failure appears to us to be the occasioning of a flow 
of blood; there should be merely sufficient to colour the wounds — 
more than this would, in all probability, wash away the minute 
portion of fluid virus usually employed. 

Medical treatment is seldom required during the progress of cow- 
pox ; nothing, in fact, is necessary in ordinary cases, except a little 
attention towards the preserving of the part from friction: when, 
unfortunately, this cannot be accomplished, inflammation is some- 
times excited, which must be treated according to the ordinary rules 
of surgery. Dr. Jenner's practice in these cases consisted in the 
application of a drop of Goulard's extract to the broken vesicle, or 
occasionally a plaster of strong mercurial ointment. With a little 
care all injury may be avoided, and we have seldom seen the em- 
ployment of any surgical means, more active than a poultice, required. 
As for internal treatment, we have never known any thing necessary, 
excepting, now and then, the exhibition of a mild aperient. 

In concluding this portion of the subject, we must not let it escape 
our recollection, that there are idiosyncrasies of constitution which 
resist our best directed efforts for the communication of cow-pox, 
and that a similar circumstance has been observed with respect to 
small-pox. When we meet with suck a case, we must, of course, 
after a fair number of trials with fresh and active virus, leave the 
patient to chance ; and after some lapse of time make another 
attempt, upon the probability of a change having taken place in the 
system. 

The term imperfect or spurious vaccination is frequently to be 
met with in books, and has been the cause of no small degree of 
confusion in practice, although, at the same time, it has frequently 
afforded the practitioner an excellent asylum against the storms now 
and then arising out of failures in the protective powers of the vaccine 
disease. This portion of the subject has received much attention 
from Dr. Willan, by whom the different appearances consequent 
upon imperfect vaccination have been divided into three varieties — 
pustules, ulcerations, and irregular vesicles. Their causes have also 
been referred, by the same author, to three classes — impurity of the 
virus, occasioned either by heat, or being taken at a late period, or 
28 



326 VACCINATION. 

by exposure to air, moisture, rust, &c. ; secondly, the system of the 
person inoculated being under the influence of any fever ; and thirdly, 
his being affected with some chronic cutaneous disorder. 

With respect to the two first varieties we may as well cut the 
knot, and save much minute and tedious description, by at once refer- 
ring to the characters of a cow-pock, as already laid down, and 
which there can be no difficulty in distinguishing from a pustule or 
an ulceration. Should either of these, then, follow vaccination, it 
must be considered not as a variety of vaccine disease, but as much 
an accidental occurrence as if the slight wound were attended by 
phlegmon or erysipelas.* With the irregular vesicles, however, the 
case is different, as they, in many instances, closely resemble the true 
disease, and in some have even furnished virus capable of exciting 
it perfectly in other individuals : three sorts have been observed by 
the distinguished physician already mentioned, which we shall 
describe pretty nearly in his own words.t The first is a pearl- 
coloured vesicle, set on a hard, dark red base, slightly elevated. It 
is globate, and less in size than the genuine vesicle, its top is flat- 
tened, or sometimes a little depressed, but the margin is not rounded 
or prominent. The second appears to be cellular like the genuine 
vesicle, but is somewhat smaller, and more sessile, and has a sharp 
angulated edge. The areola in both of these is usually more diffuse 
than in the regular disease ; in the second it is sometimes of a dilute 
scarlet colour, and radiated. The areola appears round these vesi- 
cles, on the seventh or eighth day after inoculation, (sometimes 
earlier,) and continues more or less vivid for three days, during which 
time the scab is completely formed. The scab is smaller and lighter 
coloured than in the regular disease, and falls off sooner, leaving a 
smaller and less permanent cicatrix. The third irregular appearance 
is a vesicle without an areola, which usually takes place if the person 
has previously had small-pox, or is at the same time labouring under 
some fever. The two first forms of irregular vesicles will, no doubt, 
appear to the student to have no very marked characters by which 
an inexperienced observer could distinguish them from those of a 
more genuine nature ; and the confusion, we apprehend, will not be 
diminished, when we find Dr. Willan admitting that they will in 
some cases afford full security against small-pox, although in others, 
that disease will take place after them, at different intervals, and 
under a particular form. 

The true state of the case we believe to be, that the cow-pox is, 
like other diseases, liable to some slight variations in its symptoms, 
and that, in many instances, the too enthusiastic partisans of vacci- 
nation made use of these to help them out of the dilemma in which 
the occasional failure of the practice involved them. Whenever 

* We are aware that Dr. Willan supposed that there was a real vaccine pu&tule, 
capable, in " a few instances," of communicating by inoculation the genuine vesicle. 
We have ventured above to state our own opinion, conceiving that the adoption 
of it will afford a simpler rule of practice, and remove some difficulty from the 
subject. 

f Willan on Vaccine Inoculation. 



VACCINATION. g 07 

small-pox occurred to a person who had been vaccinated, a ready- 
answer to all their doubts was furnished by the supposition of his 
having been the subject of irregular vesicles. In other instances, as, 
for example, when the areola is deficient, we must adopt Mr. Bryce's 
notion, and suppose the disease to be merely local, and not to have 
affected the constitution. An excellent rule, however, is, in all cases 
in which a shadow of doubt remains upon our minds as to the effi- 
cacy of the inoculation, always to repeat the process, and avail our- 
selves of the valuable and ingenious test of Mr. Bryce. 



In approaching the consideration of the vaccine controversy, we 
are fully aware of the extraordinary difficulties common to it, 
and every other subject involving, in any degree, the inscrutable 
principles of contagion. As we have now, however, an experience 
of the effects of vaccination in various parts of the world, during a 
period of thirty-five years, we should hope that without bewildering 
ourselves in abstruse reasoning, it will be possible to find, among 
medical records, numerical evidence sufficient to warrant us in 
placing our conclusions high upon the scale of medical probabilities : 
a rank that, it is never to be forgotten, is the very highest that can 
be obtained for any portion of a science whose data are influenced 
by the varying and unascertained laws of vitality. Of the import- 
ance of any measure that would diminish the ravages of small-pox 
it is not now necessary to speak, as it has been long since practically 
acknowledged by the adoption of variolous inoculation. Of the ad- 
vantages of the vaccination over this latter, supposing it to be equally 
preventive of small-pox, it is scarcely more necessary to adduce 
proof. We may mention, however, that cow-pox is only propagated 
by actual inoculation, while every case of inoculated small-pox be- 
comes a new fomes for the dissemination of infectious miasmata ; that 
cow-pox never terminates fatally, nor ever excites scrofula or other 
chronic constitutional diseases, but, on the contrary, has been observed 
occasionally to be beneficial in some cases of obstinate cutaneous 
eruptions; "while inoculated small-pox not only frequently produces 
blindness and other deformities, and developes scrofula in the con- 
stitution, but has been estimated by Dr. Willan to be fatal in the 
proportion of 1 to 250 cases, and by Dr. Jurin, in the large ratio of 
1 to 50. So little too was the general advantage promoted by this 
practice, however beneficial it might be to individuals, that it has 
been ascertained, by the calculations of Dr. Heberden,that, from the 
increased exposure to infection, the general mortality of small-pox 
rose, after the introduction of inoculation, from 70 to 95 in 1000.* 
So much for the personal merits (if we may so speak) of the two 
diseases. We shall now inquire, first, whether vaccination affords 
any protection, and if so, to what extent ? Secondly, has the present 
vaccine disease lost any of its properties by having passed through a 

* We quote these numbers from the Edin.Rev. vol. ix., not being able, just now, 
to lay our hands on Dr. Heberden's paper. 



328 VACCINATION. 

number of human constitutions ? And, thirdly, has the general em- 
ployment of vaccination been found to increase the mortality of other 
diseases of infancy ? 

With respect to the first part of the first query, we can have no 
more conclusive reply than is furnished by the cases recorded in Dr. 
Jenner's work, and which were made by him the groundwork of his 
reasonings upon the subject. One of the shortest of these may be 
quoted in the author's words, and will serve as a specimen of the 
rest : — " John Philips, a tradesman of Berkeley, had the cow-pox at 
nine years of age. At the age of sixty-two I inoculated him, and 
was careful in selecting matter in its most active state. It was taken 
from the arm of a boy just before the commencement of the eruptive 
fever, and instantly inserted. It very speedily produced a sting-like 
feel in the part. An efflorescence appeared, which on the fourth day 
was rather extensive, and some degree of pain and stiffness was felt 
about the shoulder ; but on the fifth day these symptoms began to 
disappear, and in a day or two after went entirely off, without pro- 
ducing any effect on the system. ,y A vast number of cases present- 
ing the general features of the foregoing were observed by Dr. Jenner 
and his friends, and form a body of evidence that could not be resist- 
ed, at a period when every mind was prejudiced against the new 
doctrine, and that would now only be weakened by an impertinent 
attempt at corroboration. With respect to the objections to those cases 
urged by Mr. Brown, of Musselburgh, (the chief opponent of vacci- 
nation, in the present day,) viz., that the individuals were either 
insusceptible, or that the protective impression was kept up by con- 
tinual exposure to infection from the cow, it will be necessary merely 
to remark, that, as in the instance quoted, many of the persons men- 
tioned by Jenner were for years removed from the influence of cow- 
pox infection, and that if we suppose them to be accidentally insus- 
ceptible, the exceptions will be so numerous, as to become of necessity 
converted into a rule. An account has already been given of the 
circumstances under which Jenner put his theory to the test of expe- 
riment, the whole, we think, proving as demonstratively as the subject 
will admit, that the general tenor of the vaccine disease is to destroy 
the constitutional susceptibility to small-pox contagion. We shall 
now, merely to show that we are not dependent for proofs upon the 
observations of others, cite one of those striking examples of protec- 
tion, many of which must fall under the observation of every person 
in the constant habit of vaccinating. About four years since we 
vaccinated with the same virus three children of the same family, 
and who were in the habit of occupying one bed. Small-pox was 
prevalent in the neighbourhood, and two of our patients were seized 
with rigors a few hours subsequent to their vaccination ; each had a 
very severe attack of small-pox ; the third, who at night constantly 
slept between these two, had a perfect vaccine vesicle, and completely 
escaped the other disease. 

In attempting to reply to the second part of our first query, a 
number of the most disputed parts of the subject, will naturally come 
under our consideration. We shall first examine a few of the most 



VACCINATION. 339 

prominent and authentic statements as to the numerical effects of 
vaccination upon mortality, and in doing so. cannot avoid expressing 
our regret at the total neglect in which the important subject of 
medical statistics is suffered to lie by the government of these coun- 
tries. In every other civilised state of Europe, the medical or political 
inquirer can obtain from the highest sources authentic records of facts, 
without which, their doctrines, that so especially involve the happi- 
ness of the human race, are but vain speculations. In England, on 
the contrary, the only fountain of knowledge is the London bills of 
mortality, and in this division of the empire we are without even the 
scanty stream of information which they supply. All that could 
have been derived from the bills of mortality on the subject of small- 
pox and vaccination, has, however, been given to the public by Dr. 
Jurin and Sir Gilbert Blane, and incomplete as it is, affords highly 
gratifying conclusions, which we shall endeavour to weave in with 
some of the more accurate records of other states. From an exami- 
nation of the bills during a period of forty-two years, Dr. Jurin* found 
that one in fourteen of all who were born died of small-pox; by 
Frank, Siissmilch,t and Black, the general mortality of the human 
race from this disease was estimated at about eight or nine per cent. 
Duvillard states that of 100 born, only four reached the age of thirty 
without undergoing small-pox, and that the mortality among adults 
affected was one in seven or eight, but among infants so much as 
one in three. For the purpose of comparing the effects of small-pox 
inoculation and of vaccination, with the unchecked effects of natural 
small-pox, Sir G. Blane t has constructed, from the bills of mortality, 
four tables of periods of fifteen years each, showing the ratio borne 
by the mortality of small-pox, to the total mortality. These are as 
follows : — in the first period, which was that immediately preceding 
the introduction of inoculation : 

From 1706 to 1720 the proportion was one in 12*7 or 78 in 
1000. 

In the second and third periods, when inoculation had made con- 
siderable progress, the proportions were, 

From 1745 to 1759, 1 in 11-2 or S9 in 1000. 
From 17S4 to 179S, 1 in 11 or 90 in 1000. 
In the fourth period, when vaccination had been some years in 
use, viz. : 

From 1804 to 1S18, only 1 in 18-9 or 53 in 1000. 

By calculations founded upon these tables, Sir G. Blane has esti- 
mated the saving of lives during the latter fifteen years, in London 
alone, at 23,134, a result very gratifying, but still alloyed by the 
reflection, that it is but a fragment of the good that, might have been 
done, were it not for our own, almost national, caprice, and childish 
refusal of the slight constraint upon personal liberty that would ac- 
crue from the legal enforcement of vaccination. From Sweden, for 

* Account of Success of Inoculating the Small-Pox, &c, 1723-6. 
t Gottliche Ordnung, &c. Berlin, 1742. 
% Med. Chir. Trans, vol. x. 
2S* 



330 VACCINATION. 

example, where the authority of government is interposed in favour 
of the measure, we are furnished with the following interesting 
document : 

In the year 1779 small-pox destroyed 15,000 persons.* 
1784 - - - 12,000 

1800 - - - 12,800 

1801 - - - 6,000 
1822 ... 11 
1S23 ... 37 

III Prussia, also, (according to Dr. Casper,t) the most marked 
advantages have followed the introduction of vaccination. In the 
years 1S20 and 1821 the deaths from small-pox were 3137, in a 
population of twenty-three millions, making one in 7204 inhabitants. 
In Berlin alone, the average annual number of deaths from small- 
pox, during the twenty years preceding 1802, was 472; during 
twenty years succeeding 1802, it was 175; since 1812 it amounted 
only to 50 ; since 1S17 to 12 ; and in 1821 and 1S22, there was only 
one death from this cause in each year. During the ten years pre- 
ceding 1823, the deaths from small-pox, compared to every 1000 
births, were as nine ; before the introduction of cow-pox, they were 
as eighty-three ; whence it would appear that seventy-four lives in 
every 1000 were preserved by the practice of vaccination. But it 
would be superfluous to multiply these statements ; the foregoing 
have been taken almost at random from the chaos of records upou 
the subject, existing in every journal, in almost every language ; and 
surely, to use the enthusiastic words of Blane, these are " benefits 
which could never have been dreamt of by the most sanguine philan- 
thropist," and which must overwhelm us " with a sense of unrequit- 
able obligation to the individual who first disclosed and promulgated 
the secret." 

Such have been the gross numerical results of vaccination, which 
would appear of themselves sufficient to obtain universal support 
for the practice. The arguments, however, of the anti-vaccinists, 
have never been drawn from the only source of any value in an 
uncertain science — a general average of facts ; but have invariably 
been built upon isolated occurrences which we shall probably find to 
be fully entitled to the character of exceptions. At the commence- 
ment of vaccination, the new disease was confidently put forward, 
as a complete and perfect preventive of small-pox, and was implicitly 
received as such by its partisans. This notion was so far fortunate 
as favouring the rapid and extensive adoption of the practice, and 
as such was wisely countenanced by its discoverer. From the 
cautious style, however, of many passages of his work, it is not diffi- 
cult to perceive that Jenner, though a parent fond of his offspring, 

* B. Hawkins on Med. Statistics, p. 143. 

t Review of J. L. Casper on Med. Statistics, in Edinburgh Medical and Surgical 
Journal, xxvi. 171. 



VACCINATION. g 31 

had sufficient of that foresight of difficulties, so peculiarly character- 
istic of genius, to enable him to perceive, that like every thing human, 
his discovery was not altogether infallible. Signs of this spirit may 
be observed in the anxiety which he exhibits to prove, that the 
occurrence of small-pox, whether casual or inoculated, does not 
perfectly extinguish, in the constitution, the susceptibility to that dis- 
ease.* It appears to us obvious, that without wishing, at the time, 
to moot the question, he perceived that if the possibility of small-pox 
occurring twice, was once established, its occasional appearance after 
vaccination, would excite neither surprise nor alarm. In the wri- 
tings of the anti-vaccinists, this view of the subject was altogether 
overlooked, and all their conclusions made to depend upon the 
assumption, that small-pox inoculation furnished a perfect and com- 
plete protection against the future occurrence of the disease. That 
it did not do so, will be proved to the satisfaction of the most skepti- 
* cal, by an examination of the cases detailed in Jenner's own work : 
and those alluded to in Moore's History of Small-Pox, and in the 
9th vol. of the Edinburgh Review, p. 62, not to speak of the numer- 
ous cases scattered through all the periodicals, and those with which 
the memory of most practitioners will furnish them, either of the 
actual re-occurrence of small-pox itself, or of those other diseases, as 
scarlatina, measles, &c, which may be supposed to furnish reason- 
able analogies. 

To exhibit the ratio in which small-pox has occurred secondary 
to itself or to vaccination, and also its mortality under such circum- 
stances, it will be useful to examine some numerical records. In 
the year 1825,t 419 persons were admitted into the London Small- 
Pox Hospital ; 2C3 had no protection, and of these 107 died ; two had 
been inoculated with small-pox, of whom one died ; and 147 had 
been vaccinated ; among the latter the mortality was 124 During 
the year 1818, small-pox was epidemic in Edinburgh, and 556 cases 
were seen by Dr. Thomson§ of that city. Of these 205 had no pro- 
tection, and 50 died, or 1 in 4; 41 had previously had small-pox, 
several being deeply marked ; 30 other cases of secondary small-pox 
were reported to Dr. T., and of the whole 71, 3 died, or 1 in 23; 
310 of Dr. TVs patients had been vaccinated, and in only one did the 
small-pox prove fetal. In Norwich,|| during the year 1819, 3000 

* Inquiry, &c. p. 116. 

t Dr. George Gregory, in Med and Phys. Journal, vol. Iv. 

{ The announcement of this mortality excited, at the time, co nsiderab e alarm, 
which was, however, quieted by a Report of the Vaccine Board, and a le Ate from 
Sir H. Halford to Mr. Hobhouse, (vide Medical and Physical Journal, ut :*«/»«,) 
showing, from Dr. Gregory's own admissions, that in not more than oneoi ^ the 
twelve cases, was there evidence of perfect vaccination. There is also a difference 
between the tot and the separate numbers, the tot being 419, ^. lle *£* + ^'S; 
make only 412. We have, however, inserted the report, as alt hough it may be 
considered one of the most unfavourable that has been ever made upon the > subjec 
the mortality it shows from small-pox after vaccination is only eighteen*. • * ™° 
that from secondary small-pox is fifty, and that from the uninfluenced disease 
upwards of forty per cent. 

§ On Varioloid Diseases. 

U Cross on Varioloid Epidemic, Lond. 1820. 



332 VACCINATION. 

individuals caught small-pox, of whom 530 died ; it was estimated 
that there were in that city 10,000 persons who had been vaccinated, 
and that of these 2 in 100 caught small-pox ; only six of them, how- 
ever had it in a perfect form, of whom two died. The disease also 
•proved fatal to one individual who had previously undergone vario- 
lous inoculation. These numbers speak for themselves, and when 
contrasted with the natural small-pox mortality, of 1 in 5 or 6, 
loudly and unanswerably proclaim the great advantages of vaccina- 
tion. It appears, however, that although the mortality of small-pox 
in those who had undergone cow-pox was very trifling, still a con- 
siderable number of the vaccinated actually underwent the disease, 
but only when variola prevailed as an epidemic, as inoculation alone 
has not been found sufficient to overcome the preventive influence 
of vaccination. 

The reader will naturally be led to inquire, why, in the same epi- 
demic, the disease is found to be so mild in the vaccinated, and so 
severe and fatal in the unprotected. The reason is obscured by the 
same veil that envelopes the cause of the usually singular occurrence 
of some diseases, and which, in all probability, will never be pene- 
trated by human eye. The fact, however, is, that small-pox secon- 
dary to itself, or to vaccination, becomes very different in many of its 
symptoms from the uninfluenced disease ; and it is upon this power 
of modifying, when it cannot altogether prevent, that the claims of 
cow-pox as a protective agent must now be rested. 

The observations and experiments of Dr. Willan,* enabled him to 
form some conclusions upon this modifying power, the substance of 
which it may be useful to state : 1st. inoculations with vaccine and 
variolous matter, performed upon the same person at the same 
period, or with an interval of not more than a week, were both found 
to prove effective to a certain extent, so far as to produce a vaccine 
vesicle, and variolous pustules, each respectively capable of communi- 
cating their peculiar infection to other individuals ; 2d, that when 
variolous matter was inserted on the ninth day after vaccination, its 
action seemed to be wholly precluded ; and, 3d, that when the two 
diseases took effect as mentioned above, they always modified and 
restrained each other, an irregular vaccine vesicle being produced : 
and a variolous eruption of " hard, distinct, shining pustules, which 
have butlittle inflammationTound them,'and which seldom maturate, 5 ' 
resembling strongly those varieties of variola, called by the older 
writers " stone-pox," " horn-pox," " siliquose-pox,"t &c„ &c. 

It is this modified disease, then, which occurs in almost every in- 
stance in which small-pox attacks a person who had previously been 
the subject of cow-pox inoculation. That a similar mild form of 
small-pox sometimes occurs naturally, and in an epidemic form, may 
be inferred from the descriptions in old works of those eruptions 
named above. Jenner also mentions an epidemic of a peculiarly 
mild nature, which spread through several towns of Gloucestershire, 

* On Vaccine Inoculation, 1806. 

f For an accurate and interesting description, see Thomson on Varioloid Dis- 
eases. 



VACCINATION. 333 

and was witnessed by himself. A similar variety was described 
under the name of pearl-pox, by Dr. Adams,* who hoped to substi- 
tute it for the ordinary sort, by successive inoculations from the mildest 
cases. The mildness, however, appears to depend upon the constitu- 
tion of the individual epidemic; as it was found by Willan, and 
others, that inoculation from pustules, modified by vaccination, pro- 
duced occasionally the worst forms of the disease. This modifying 
influence appears to be possessed by small-pox itself, and to affect 
its secondary attacks ; it is supposed, however, by Thomson and 
Bryce,t to be less efficient in tins respect than cow-pox ; and the 
same opinion appears to be entertained by Dr. Mohl, of .Copen- 
hagen,;}; as he records 31 fatal cases out of 153 of secondary small- 
pox. 

Before leaving this part of our subject we must (though with ex- 
treme reluctance) notice the remarks of Dr. Gregory, in the 12th vo- 
lume of the Med. Chir. Transactions. We confess, in our anxiety to 
avoid controversy, we should have evaded doing so altogether, were 
it not that Dr. G. has subsequently informed us,§ that his paper has 
excited the favourable attention of the profession ; and that the paper 
itself, from its dubious style rather than its sound arguments, is well 
calculated to produce an injurious effect upon the minds of casual 
readers. In the first place, then, with respect to the increasing num- 
ber of cases of small-pox after vaccination — when it is considered 
that the number of the vaccinated to take small-pox is every year 
increasing, the surprise, probably, will be lessened; and perhaps alto- 
gether removed, when we find that Dr. G.'s cases were "after pre- 
sumed as well as real vaccination." Again, as to the manner in 
which variola is modified by vaccination, Dr. G. alleges that neither 
the eruptive fever, nor quantity of the eruption is usually lessened, 
nor the effect of the poison upon the brain and nervous system ren- 
dered less fatal. As to the first assertion, it will be best met by the 
Doctor's own account of fifty-four out of fifty-seven cases being 
" discharged in perfect health ivithin fourteen days from the period 
of their admission." || In proof of his second position, respecting 
the fatal effect of the modified disease upon the brain, he has adduced 
two cases. One of them, however, is that of a drunken " labourer 
in lead works," and the other of death from erysipelas following 
venesection for ophthalmia in a woman who had gone through small- 
pox, but in whom (according to himself) " vaccination was not trust- 
worthy." In three other cases out of the five fatal he admits that 
one had no cicatrix, and the other two had cicatrices large and irre- 
gular. Amidst the dark hints of Dr. Gregory, the partisans of vacci- 
nation will generally find some gleams of encouragement. He tells 

* Popular View, &c. London, 1807. 

f Thomson, Op. eit. pp. 60 and 202. 

% De Variolidibus et Varicellis. Copenhagen, 1827. 

§ Medical and Physical Journal, vol.lv. 

|| By the way, if Dr. G. discharged fifty-four cured out of fifty-seven, it is not easy 
to understand by what process of arithmetic he had a remainder of five fatal cases . 
Vide Trans, p. "334. 



134 



VACCINATION, 



us, for example, that George Ferriman,who had been inoculated for 
small-pox, was admitted into the hospital with "pretty severe" modi- 
fied variola, and that with him were admitted his two children, who 
had been vaccinated, both labouring under a " very slight" form of 
the same disease ; and again, that the large majority of his patients 
had been vaccinated in the country, and "had large, irregular, and 
therefore imperfect ^cicatrices." 

Another observation was contained in the paper now alluded to r 
and was more developed in subsequent papers,* which, we fear, has 
been the occasion of much disturbance in the public mind. It was, 
" that the majority of cases of small-pox, after vaccination, which 
have occurred at the small-pox hospital, have been persons between 
the ages of 15 and 21." Upon this was afterwards built a revival 
of Mr. Brown's opinion, "that the influence of cow-pox on the sys- 
tem wears out in the progress of life, and requires periodical renew- 
als."! Mr. B. thought that the influence wore out in six years, Dr. 
Gregory extended the period to ten. A brief allusion to Mr. Brown's 
conception of and practice in the vaccine disease will enable us very 
shortly to dispose of his share in the argument. He contends that if 
you only have a vesicle with an areola, you may depend upon the 
production of whatever effect cow-pox is capable of: again, in his 
practice he surrounded the punctures with a stripe of flannel, used 
gentle violence, made the child lie on the inoculated arm, and took 
no virus until the areola was formed. J Dr. Gregory asserts that he 
has not been able to re-vaccinate children under ten years, and that 
the same age is the earliest at which he has seen small-ppx among 
the vaccinated. He admits, however, that he has met resistance 
after twenty-five years ; and as to the table in his first paper, like 
many an edged tool, it cuts both ways, having a descending scale 
from the age of twenty, as well as an ascending one to it. Dr. Mohl, 
of Copenhagen, in some degree advocates the same opinion, at least 
he thinks that the modifying influence is somewhat weakened by time, 
but his scale is liable to the same objection as Dr. Gregory's : he 
found, 

Under 3 years - Cases. 

5 ... 14 

Between 5 and 10 - - 102 

10 and 15 - - 173 

15 and 20 - - 1S7 

20 and 25 - - 156 

Above 25 - - 21 



653 



Dr. Thomson found the modified disease to occur, on the other 
hand, at every period after vaccination ; and Jenner, with his usual 
foresight, " selected in his first work cases in which the disease (cow- 

* Medical Gazette, vol. viii. 

t Med. Chir. Trans, vol. xii. p. 336. 

% Inquiry, and Edinburgh Medical and Surgical Journal, 1819. 






VACCIXATIOxV. 33s 

pox) had appeared at a very distant period, previous to the experi- 
ments made with variolous matter, to show that the change produced 
in the constitution is not affected by time." The periods he alludes 
to are from 25 to 53 years, so that we think, if the gentlemen who 
have taken up the other side of the question have no better proofs 
than those they have as yet advanced, we may safely set down their 
allegations as not proven. 

Dr. Jenner's hypothesis of the identity of variola and the variolse 
vaccinae (to use his phrase) has been already alluded to ; whether 
it be true or false is a matter rather curious, than of any practical 
utility. ^ It will be enough to say, that the present phenomena of the 
two affections are materially different, and it is probable that an 
attempt now to trace their affinity would only result in rendering the 
obscurum, obscurius* A novel and interesting idea has, however, 
been more lately started by Dr. Thomson, viz., that varicella, modi- 
fied small- pox, horn-pox, swine-pox, stone-pox, &c, are all only 
varieties of the common small-pox. A modification of Dr. Thomson's 
views has since been proposed by Lichtenstadt,t of Breslau, viz., 
that varicella was originally a mild offshoot from variola, which has 
become gradually so weakened by transmission, as now to be inca- 
pable of producing small-pox ; but that it still occasionally arises 
directly from that disease, as at first. Dr. Thomson's hypothesis 
owed its origin to some inoculations performed by the late distin- 
guished Dr. Hennen, with matter taken from an eruption which 
appeared upon his son, and was supposed at the time to be vari- 
cella. By these experiments, eruptive diseases of different degrees of 
severity, varying between the mildest varicella and severe small-pox, 
were communicated to several individuals; at the same time Dr. T. 
observed, in different parts of Edinburgh, natural and modified small 
pox, and chicken-pox, " co-existing in the same situations, and ap- 
pearing in their progress to produce one another." A variolous 
epidemic was existing in Edinburgh at the time, and from the fore- 
going circumstances he was led to conceive, that all its various ap- 
pearances in the different classes of persons whom it attacked, might 
be produced by the operation of one and the same contagion. On 
the other hand, Dr. Mohl, of Copenhagen,! has observed varicella at 
periods when there was no variolous epidemic, and again has seen it 
to occur sporadically at the same time with, but independently of, the 
other disease. The question appears to turn upon the exact defini- 
tion given to varicella, and we must confess that no description that 
we have seen would enable us to form a diagnosis between it and 
the vesicular variety of small-pox. An able revie wer§ has laid down, 

* The correctness of Jenner's views has been completely proved by the interest- 
ing experiment of Mr. Ceeley, of Aylesbury ; for a detailed account of which see 
the Medical Press, vol. ii. p. 120. Mr. C. succeeded in communicating small-pox 
to young cows by inoculation, the affection thus produced in these animals being, 
in all respects, similar to the true vaccine disease, and capable of being re-com- 
municated to the human subject. [Note to 3d Edition.] 

f Hufeland's Journal, June, 1820. 

X Op. cit. 

§ Edin. Med. and. Surg. Journal, April, 1820. 



S 36 VACCINATION. 

with a good deal of confidence, what he conceives to be certain dia- 
gnostic marks, the substance of which we shall give, but indeed with 
little hope of their being available in practice. The eruptive fever, 
he says, in varicella, is slight ; Dr. Will an, however, has often seen 
it attended with convulsions ; secondly, the eruption is vesicular 
from the beginning, or at least from the early part of the first day, 
not papular, as vesicular variola always is at first ; thirdly, the tuber- 
cular basis of the vesicles is absent in varicella ; yet Dr, Willan found 
" the -sensation communicated to the finger, like that from a round 
seed flattened by pressure,"* and the reviewer admits that chicken- 
pox sometimes acquires a tubercular base at a late period, while 
variola as often loses it : fourthly, varicella is to be known by the 
thinness and fragility of the covering of its vesicles, and by being 
found between the skin and the cuticle, while variola always exists 
in the true skin. With every disposition to acknowledge the talent 
shown in the review in question, we cannot but express our opinion, 
that the foregoing characters are rather the result of meditation in 
the closet than of observation by the bedside, and that as far as we 
have been able to see, ourselves, or examine into the opinions of 
others, the theory of Dr. Thomson appears to us to be still unim- 
pugned. 

Having now, we trust, entered, sufficiently in detail, upon the 
points embraced by our first query, it is time to return to the other 
two, which, however, will not require so lengthy a discussion. 

The second inquiry proposed was — Has the present vaccine dis- 
ease lost any of its properties by having passed through a number of 
human constitutions ? The answer must, in a great, measure, depend 
upon the case already made out for the actual protective properties 
of cow-pox at the present time. In addition, we may mention that 
it is in the power of every person to satisfy himself that the vaccine 
vesicle of to-day is, in all respects, an original for the delineations of 
the same disease given by Jenner, in 179S ; that we have no analo- 
gies in favour of deterioration, e, «•., measles, scarlatina, plague, &c, 
are identical with the same maladies, according to the descriptions of 
the old authors ; and that as small-pox itself has not lost its virulence 
from time alone, we can have no solid reason for supposing that the 
same agent could have a material effect upon its opponent. 

Our third query was — Has the general employment of vaccina- 
tion been found to increase the mortality of other diseases of infancy ? 

The affirmative of this question was advanced by Dr. Watt, of 
Glasgow, in the appendix to his Essay on Chincough, and in the 
Edinburgh Med. and Surg. Journal, vol. x., and his views passed 
current, both at home and abroad, until Mr. Roberton, of Manches- 
ter,-^ detected a fatal error in his calculations. Dr. W. found, from 
the Glasgow tables, that from six years subsequent to 17S2, the 
deaths, under ten, were 53-48 per cent, of the total deaths, whereas 
in the six years previous to 1S12 they were 55*43 per cent. Hence 

* On Vaccine Inoculation, p. 95. 
f On Mortality of Children, 1827. 



VACCIxVATION. . 3 



he inferred that the mortality of children had not improved, and that as 
a manifest diminution had taken place through the abatement of 
small-pox, this must have been compensated by a corresponding 
increase of deaths from other diseases of children. In his inference 
Dr. Watt did not take into account the diminution that had taken 
place in the general mortality, nor the increase of the population • 
and accordingly we shall find, by referring the infantile deaths to the' 
latter, both as found in Dr. W.'s tables, that in the early period the 
average annual mortality was one in 26-7, and the deaths under ten, 
53-48 per cent. ; that is, among every 1000 of the population there' 
died annually 37-45, of whom 20-03 were under ten ; and that in the 
latter period the annual mortality was one in 40-8, and of the deaths, 
55-43 per cent, were under ten; that is, in every 1000 inhabitants 
24-51 died annually, of whom 13-58 were under ten ; showing in 
reality a decrease of deaths among children to two-thirds of what 
they were in the former period.* In corroboration of this view, we 
may quote Dr. Casper, who found that in Berlin, during the twenty 
years before 1799, the deaths under puberty were to the births as 51 
to 100, while in the eight years succeeding 1814, they were only as 
42 to 100 ; and that in the first period the deaths from measles and 
scarlatina were 14§ to 1000 ; in the second, only 12£ to lOOO.t 

In conclusion, we shall advert to one other point, upon which we 
conceive a misconception has arisen. It has been asserted, that cer- 
tain writers upon political economy declared themselves hostile to 
vaccination. We believe they did no such thing, but that the accu- 
sation was founded upon the opinion which they expressed, that the 
limits'of increase in population were determined by those of the pro- 
duction of food, and that the numbers of mankind must maintain a 
ratio to the quantity of food that is to support them, notwithstanding 
the havoc of a pestilence ; or the diminution of mortality produced 
by a powerful agent of health. As well as we recollect, Malthus 
has, in his late editions, expressly cleared himself from the imputa- 
tion ; but without at all entering into the doctrine of population, it 
must be obvious that no man in his senses, treating upon the means 
of improving the happiness of the community, could advocate the 
designed continuance of a disease that frequently leaves those who 
survive its attack, burdens to themselves and to society. If the 
political economists proposes to keep down the numbers of mankind, 
it must be by checking their production, in the first instance, not by 
cutting them off prematurely after they have been produced. 

* The coup de grace has been given to Dr. Watt's error by an ingenious paper 
read lately before the Glasgow Med. Soc. by Mr. Cowan of that city, 
f Op. citat. 



29 



338 CONSTITUTIONAL DISEASES. 



CHAPTER XIII. 

CONSTITUTIONAL DISEASES. 
I. SCROFULA. 



A pull discussion of this subject properly belongs to the province of 
writers upon the general practice of physic ; and it would, therefore, 
be out of place, in the present work, to devote a lengthened space to 
it. As, however, a scrofulous predisposition appears in many cases 
to be coeval with the existence of the individual subject to it, and as 
it may be kept dormant by proper management, or again, by an 
opposite course, may be induced in those not originally possessing it, 
so we feel it necessary to consider briefly its general nature, and the 
principles to be held in view in its treatment, whether preventive or 
remedial. 

Symptoms and Marks of a Scrofulous Habit. — These have 
been laid down with great confidence, (although often with con- 
siderable difference of detail,) by systematic writers, ever since 
the time of Galen. Any value, however, which we may be dis- 
posed to attach to them must be modified by the recollection, 
that scrofula can be excited by certain fortuitous occurrences in 
individuals who have no especial natural tendency towards it, 
and consequently we may meet with actual scrofula in persons 
who do not exhibit the ordinary characteristics of the strumous 
diathesis. These characteristics, as most universally agreed upon, 
are — a white and transparent skin, which, from its thinness, 
making the colour of the blood particularly visible through it, 
often gives the appearance of a blooming or hectic complexion ; 
fair, or red, and soft hair ; large and well opened eyes, with dilated 
pupils ; thickness and liability to chapping of the upper lip and 
alae nasi ; large head and joints, but contracted chest; fingers long, 
and swollen at the extremities, with hooked nails ; the muscular 
parts flabby and ill developed ; the general surface of the skin 
delicate and subject to irritations, as from chafing or chilblains, and 
the whole constitution irritable and prone to febrile excitement from 
slight causes. The feelings and intellect often partake of the corpo- 
real irritability — the person being ardent and warm-tempered, 
sometimes with a remarkable quickness and precocity of talent. In 
many cases we shall find the strumous diathesis existing in indivi- 
duals of small stature and weak or deformed bodies ; but its charac- 
teristics will often be present to a considerable extent, in persons 
large and well formed. Occasionally we shall find the skin, not de- 
licate and transparent, but thick, sallow, and liable to eruptions, the 
person then usually having a heavy, stupid aspect, with full and 
drooping eyelids. As might readily be anticipated, the condition of 



SCROFULA. 33g 

the constitution just described is likely to be accompanied by an 
imperfect performance of the functions of organic life. The circula- 
tion is usually languid and feeble, and the digestion so frequently 
deranged as to lead some writers to consider a peculiar form of dys- 
pepsia as one of the most characteristic features of the strumous 
habit.* The collection of symptoms, however, to which the term 
strumous dyspepsia has been applied, we are rather inclined to de- 
signate as tuberculous fever. It is, in fact, nothing more than infan- 
tile remittent fever in a slow form, which, although often dependent 
upon the presence of worms or other source of irritation in the intes- 
tinal canal, may (much more frequently than is supposed) be occa- 
sioned by the development of scrofulous tubercles in some part of 
the system. The disease is well described by Dr. Todd in his paper 
already alluded to, but we object to his naming it dyspepsia, as being 
likely to have the eifect of directing the attention exclusively to 
the abdomen as the seat of mischief ; whereas we have reason to be- 
lieve that the primary irritation may exist in the head or other parts. 
Dr. Todd admits that hydrocephalus and various other affections, 
may show themselves in strumous dyspepsia, but he considers these 
as secondary irritations, while our view differs from his, and from 
that generally adopted, in the essential point, that we believe symp- 
toms identical with those of infantile remittent fever frequently attend 
upon a primary localization of scrofulous action in the brain and 
other parts as well as in the abdomen. For a description of the 
symptoms of tubercular fever we must refer to our section upon re- 
mittent fever at page 242, there being usually no appreciable differ- 
ence between the affections. A great many other marks of scrofula 
will be found in express treatises upon the subject, but those we 
have given form the main and striking features of the strumous 
diathesis .t 

When the disease is actually called into existence, it may affect, 
although with different degrees of frequency, almost every tissue in 
the body ; and, indeed, it appears that any morbid condition occur- 
ring in a person with scrofulous diathesis, will be likely to be more 
or less modified by its influence. The susceptibility of different 
tissues to its invasion varies according to the age of the individual ; 
children — to whom our observations have immediate reference — 
most commonly suffering the effects of scrofula in the mucous mem- 
branes, glands of the neck, and those of the mesentery. We have, 
however, seen true tubercular phthisis, with very extensive cavities 

* See article Indigestion, by Dr. Todd, in Cyc. Pract. Medicine. 

f This term and that of scrofulous diathesis or habit, we use throughout this 
article in precisely the same sense as Dr. (now Sir James) Clark, employs the 
term Tuberculous Cachexia, in his admirable Treatise on Pulmonary Consumption 
and Scrofula, a work which, though published in 1835, we had not the pleasure of 
seeing until after the publication of the first edition of the present vol, but which 
we now refer to with peculiar satisfaction, as containing opinions identical with 
those which we ventured to advance upon the various subjects included in our 
chapters upon Physical and Moral Education. Upon these, as upon all other sub- 
jects to which he has directed his attention, Sir James Clark has shed a light 
from which we should have been delighted to borrow. [Note to 2d Edition.] 



340 CONSTITUTIONAL DISEASES. 

in the lungs, in children under five years of age. The affection of 
the mesenteric glands has already been considered (as a disease 
peculiar to childhood), under the head of Tabes Mesenterica ; and 
we shall now advert to the affections of the glands of the neck, and 
of the mucous membranes of the eye, ear, and of the vagina. We 
shall do so briefly, however, as they are, by no means, peculiarly dis- 
eases of childhood. 

a. Scrofula as it affects the Glands of the Neck. — These glands 
are seldom affected in children under two years of age, and are most 
commonly subject to the disease between the fifth year and puberty. 
When first affected, which often appears to be in consequence of 
irritation from eruptions on the scalp or behind the ears, or as a 
sequela of measles or scarlatina, the glands swell, and feel to the 
touch firm and fleshy. Their texture, however, is not at this period 
much altered, quicksilver passing readily through their vessels, as 
has been proved by the injections of Sommering. By degrees, and 
often very slowly, the gland becomes larger and harder, parts of it 
sometimes being as firm as cartilage, and finally a process of soften- 
ing takes place in particular spots, which, if then examined, would 
be found to contain a soft, yellowish-white, and cheesy, tuberculous 
matter. The softening continues until a species of curdy, yellowish 
pus is formed, which slowly makes its way to the surface, often 
through several apertures, when an open scrofulous abscess results. 
The natural tendency of scrofulous glands, or tubercles, is to soften 
and produce a whey-like, purulent fluid : but they may attain a very 
large size, still continuing hard, and finally be absorbed without any 
suppuration, probably in consequence of some improvement in the 
state of the general health. Most commonly, several glands are 
affected simultaneously, or in quick succession, a chain of tumours 
being often formed along the entire side of the neck, or beneath the 
jaw from one side to the other. 

After a scrofulous abscess has burst, a slow process of enlargement 
goes on in the opening, and an indolent sore is formed, which con- 
tinues, frequently for a very long period, to discharge a thin fluid, 
containing curdy flakes and occasionally small masses of tuberculous 
matter. The sore is characterised by a thin, overhanging, livid 
margin, with pale and flabby, or indistinct granulations. There is 
seldom any pain or uneasiness. The sore remains indolent for a 
long time ; or sometimes heals in one part, and breaks out afresh, or 
spreads to another. When cicatrices are formed, they are wrinkled, 
and irregular in appearance, often crossed by projecting bands of 
skin, and producing much deformity.* 

b. Scrofulous Ophthalmia. — Strumous children are exceedingly 
liable to inflammation of the tunica conjunctiva of the eye, which 
puts on the following characters. The edges of the eyelids are at 
first slightly red and thickened, and the secretion of the Meibomian 
glands altered, so as to cause glueing together of the lids during sleep. 

* The disease sometimes, but more rarely, attacks other glands, as those of the 
groin or axilla ; its progress, however, being similar to that just described. 



SCROFULA. 



341 



On everting the lids, we find the conjunctiva covering them some- 
what redder than natural ; but the same membrane upon the eyeball 
has, at this time, probably nothing remarKable in its appearance, 
except its being traversed by a few enlarged vessels. The inflam- 
mation slowly increases, and the conjunctiva becomes gradually more 
vascular, — the eye watering, and being very intolerant of light. 
This latter symptom is usually so remarkable, that the disease may 
be known, even without looking at the eyes, by the stooped position 
in which the patient carries his head, for the purpose of diminishing, 
as much as possible, exposure of the eyes to light. 

As the disease goes on, a marked disposition to the formation of 
pustules is evinced. They appear upon the margins of the lids, and 
in the Meibomian follicles, in which situations they run into ulcera- 
tion, and produce great irritation and distress. Pustules are also 
formed upon the conjunctiva of the eyeball, or upon the cornea, a 
pencil of red vessels being developed in connexion with each. When 
this happens upon the cornea, a troublesome ulcer is likely to follow ; 
a general dulness of that texture is also usually produced ; or a per- 
manent opacity of a part of it, to a greater or lesser extent, which may 
end in total blindness. We have frequently observed, in children, a 
form of ulceration of the cornea, notice of which we do not recollect 
to have seen in works upon the subject ; it is a removal of a patch of 
the conjunctiva which covers the cornea, without the production of 
any opacity. It appears exactly as if a small portion of the mem- 
brane had been removed by a sharp chisel, leaving a distinct facet, 
sometimes level, and in other instances concave. An experienced 
eye will easily detect this lesion, by the peculiar reflection of the rays 
of light which it occasions ; but frequently we can actually see the 
defect only by looking at the part in profile. This condition may 
remain unaltered for a considerable length of time ; and so far as our 
experience goes, local applications, especially those of a caustic 
nature, are always injurious. 

c. Scrofulous Disease of the Ear. — The lining membrane of the 
external auditory passage is often the subject of inflammation in 
scrofulous children. The affection is quite analogous to that of the 
eyes, consisting in a slow inflammation of the membrane, attended 
by the formation of pustules, and protracted discharge of unhealthy, 
and often fetid pus. This form of disease is always to be looked 
upon as dangerous, as the inflammation may slowly extend to the 
internal ear, causing ulceration of the tympanum, and destruction of 
the auditory bones, thus producing incurable deafness. It also not 
unfrequently extends to the petrous portion of the temporal bone, 
and thence into the cavity of the skull, when convulsions and death 
are the certain and sudden result. p 

Ulcerations behind the ear, in the angle between it and the head, 
are common attendants upon the affection of the passage, and are 
often to be looked upon as a beneficial source of derivation with 
regard to the latter: they should, therefore, not be incautiously 

meddled with. ' . • ... - .. 

d. Scrofulous Discharges from the Vagina. — Children of a stru- 

29* 



342 CONSTITUTIONAL DISEASES, 

mous habit are liable to purulent or muco-purulent discharges from 
the vagina, which require to be understood by practitioners, who 
are often consulted respecting them, in consequence of unpleasant 
suspicions arising as to their being of a specific nature, and having 
been communicated by infection. Looked upon in this light, such 
discharges may become the subjects of legal investigation ; and in 
every such case, no opinion should be given without the most care- 
ful examination as to their real nature. Other marks of a scrofulous 
diathesis will commonly be present, but they may not be very decided- 
ly so ; and the occurrence may appear to be a good deal connected 
with a deranged condition of the bowels. It is a very obstinate 
affection, and only yields to improvement of the general health. 

Pathology of Scrofula. — A consideration of this subject involves 
questions of considerable difficulty, into which we cannot here enter 
at length, and shall therefore merely state what appears to us to be 
the most rational views upon the subject. 

It does not appear that scrofula is the product of any peculiar virus, 
as direct attempts to propagate it by inoculation have been unsuc- 
cessfully made by Kortum,* Goodlad,t Hebreard,J Le Pelletier,§ &c. 
We must, therefore, abandon this opinion of the older physicians, 
and seek for another more accordant with the present state of our 
knowledge. 

From what we have already stated, it appears that the constitu- 
tions of some individuals are decidedly predisposed to the occurrence 
of scrofula ; and that marks are recognisable, whereby we may esti- 
mate the existence of such predisposition. These marks are all such 
as denote a preponderance of the white tissues and fluids of the body 
over the red, — or, in other words, of the lymphatic over the arterial 
and venous system. Our physiological knowledge leads us to the 
inference, that the strength, and vitality, and capability of resisting 
disease, possessed by animals, (at least, warm-blooded animals,) is in 
a direct ratio with the preponderance of the red tissues and fluids in 
their bodies over the white ; that, in fact, the white tissues have 
naturally a lower degree of those qualities than the red, — and the 
more they abound in the system, in relation to the others, the less 
power will there be for struggling against morbid conditions. 

It appears, also, that individuals who do not naturally possess the 
marks of a strumous diathesis, may become scrofulous by the opera- 
tion of certain external causes, and that these are such as favour the 
production of a preponderance of the white over the red tissues, 
e.g., confinement, in a damp, unhealthy situation, with defective diet 
and a diminution in the supply of solar light and fresh air. Whoever 
looks upon the blanched aspect of hand-loom weavers, or of the 
youthful inhabitants of cellars, in some of our confined streets, will 
be at no loss to understand the operation of these causes in producing, 
at least, a diminution of the redness of health ; and medical men 

* De Vitio Scrofuloso, Lemgov. 1798. 
f On the Lymphatic System, Lond. 8vo. 
% Dissert, sur les Tumeurs Scrof. Par. 8vo. 
6 Sur la Maladie Scrofuleuse, Par. 1830. 



SCROFULA. 343 

know that such individuals are very prone to scrofulous disease 
Animals, also, taken into confinement from a wild state, frequently 
fall victims to scrofula — most of our parrots, monkeys, and tame 
rabbits, dying of tubercular consumption : while again, in the vege- 
table kingdom, an analogy is furnished with regard to the effects of 
want of light and air, in causing increase of the white tissues, by the 
appearance of any plant which has grown in a dark, confined situa- 
tion. If, then, we have the marks of a scrofulous predisposition, 
identical with those of a preponderance of white tissues, and if we 
find also that the same causes which produce the latter state, may 
also produce the former, we have some warrant for inferring that the 
scrofulous diathesis is nothing more than a state of general ill-health 
occasioned by a deficiency in the proper supply of red blood, and 
consequent preponderance of white fluids and tissues ; and that the 
different forms of scrofula are probably but local exhibitions of irri- 
tation, modified by the predisposition in question ; but which irrita- 
tions, if occurring in a healthy subject, would in all likelihood either 
be repelled without injury, or merely produce common inflamma- 
tion. 

Upon these principles, we can account for the hereditary transmis- 
sion of the disease, and for its occasionally passing over generations. 
It accords with any knowledge we possess respecting reproduction, 
that peculiarities of structure have a tendency to be communicated 
from parent to offspring ; therefore, we should expect the deficiency 
in red tissues, constituting the scrofulous diathesis, to be bequeathed 
by a strumous father or mother to their child, and accordingly we 
find that it frequently so happens. On the other hand, we know 
that fortuitous circumstances may produce a like condition of the 
two sets of tissues in individuals not born with it ; and so we see 
how scrofula may arise independently of hereditary descent. Again, 
every one is aware of the increase of ruddiness and strength effected 
in delicate persons by active exercise in the open air, — this ruddi- 
ness being nothing more than an evidence of an increase in their 
store of red blood; hence we know why scrofula may pass over a 
generation better circumstanced as to air and employment than that 
which preceded it ; and we are also taught to hope that, by suitable 
means, much may be done, both in the prevention and cure of this 
scourge of the human race.* 

* Mr. Carmichael in his admirable clinical lectures, while he rejects the idea of 
scrofula being occasioned by any peculiar poison transmissible from parent to child, 
says : — " No doubt numbers come into the world predisposed to the disease ; but 
these are the children of sickly or debilitated parents ; no matter from what cause 
their debility may have arisen. Thus the offspring of the valetudinarian — the 
dissipated debauchee — the drunken sot — or the old gouty man of pleasure, may 
be esteemed predisposed to scrofula. Even the children of old men, though healthy, 
appear to be in this predicament. A few years since, I was consulted on account 
of two children, a boy and a girl, under ten years of age --the one had caries of 
the vertebrae — and the other hip-joint disease in its second stage. 1 he lady under 
whose care they were, who was herself apparently fifty years of age, told me that 
these children were her brother and sister —seeing some surprise in my counte- 
nance, she added, ■ but by different mothers. My father, when eighty years ot age, 



344 CONSTITUTIONAL DISEASES. 

With respect to the essential character of scrofulous disease, the 
most certain is the production of tuberculous matter, which is defined 
by Dr. Carswell* to be " a pale yellow or yellowish-grey, opaque, 
unorganised substance, the form, consistence, and composition of 
which, vary with the nature of the part in which it is formed, and 
the period at which it is examined."! The seat in which this matter 
is commonly deposited has been also shown, by the same author, to 
be the mucous system, although it was formerly supposed to be the 
cellular tissue. His view, however, appears to us to corroborate the 
opinions already advanced, as to the pathology of the disease : the 
mucous systems require, for the discharge of their functions, a large 
share of red blood, and a high degree of vitality; consequently it 
is to be expected that they will suffer soonest and most severely 
from any minus state of the constitution in these particulars. 

Although the deposition of tuberculous matter is a sure evidence 
of scrofula being present, still we must admit the disease to exist, 
although no such formation may have taken place. In the affections 
of the eye, ear, and vagina, for example, there is no tuberculous 
matter deposited ; yet we cannot doubt that they are strumous, both 
on account of the manner of their progress, and of the constitutions 
of the individuals whom they affect. 

It has been supposed by some, that tubercle always had its origin 
in inflammation : and were it not that the authors of this theory 
have endeavoured to form for it an unlawful and dangerous union 
with practice, by recommending depletive measures for the cure of 
tuberculous disease, we should pass it over as one of those idle 
disputes about words unfortunately so common among physicians. 
Our opinion upon the subject may be inferred from what we have 
already stated ; we believe that irritations which would produce no 
effect upon the healthy, originate tubercle in the scrofulous; and 
also that lesions capable of exciting inflammation in the former, 
would excite tuberculous deposition in the latter. The cure of in- 
flammation in the healthy, however, is to be effected by the abstrac- 
tion from their system of red blood; while the cause of the scrofulous 
disposition we believe to be a deficiency in the same fluid — conse- 
quently, it cannot be cured by making that deficiency more consider- 
able, and therefore, (in a therapeutical sense, at least,) is not to be 
looked upon as inflammation. 

thought proper to marry a second time; the family he had by his first wife are, like 
myself, all stout and healthy (indeed she appeared the very personification of stout- 
ness), while the family he had by his second wife, like those you see before you, are 
all mere sickly blights.' I then inquired if the mother of the latter was healthy, 
and was told that she was a remarkably fine healthy looking woman, and nursed 
three children herself — the inference is obvious." Mr. C. also strongly advocates 
the opinion, that close intermarriages between blood relations tend much to the 
production of a scrofulous progeny. See the Medical Press, vol. iii. p. 3. [Note to 
3d Edition.] 

* Illustrations, &c. London, 1833. 

f Mr. Carmichael conceives the tubercle of the lungs to be essentially different 
from the matter of scrofulous tumours ; according to his opinion, the former is to be 
considered as an independent parasitic formation. See his lectures in the 3d vol. 
of the Medical Press, passim, [Note to 3d Edition.] 



SCROFULA. 345 

Preventive Treatment— Viewing the scrofulous diathesis as a 
minus state of the red fluids and tissues, the obvious means of pre- 
venting the development of the evil effects of this condition must be, 
to restore the system to its healthy balance, and so to preserve it. 
How this is to be attempted has been already considered at some 
length, in the chapters upon the Management and Education of 
Children, and need not be again dwelt upon. What we want to 
accomplish is, the establishment of a good state of health ; and this 
can only be arrived at by a careful working out of the principles 
laid down in those chapters under the heads of focd, clothing, &c, 
&c. In cases of a marked scrofulous predisposition, we may recom- 
mend, in addition, a residence at the sea-side during three or four of 
the summer months, which, without supposing the sea to possess 
any specific, antistrumous qualities, must certainly be looked upon 
as likely to produce very beneficial tonic effects. No specific medi- 
cal treatment is required or warranted for the prevention of scrofula. 

Curative Treatment of Scrofula. — This is to be based upon 
principles precisely similar to those of the preventive treatment. 
The general health must be improved by means suitable to the par- 
ticular case, and all causes of local irritation must be, as far as pos- 
sible, removed. The means of working out these principles must, 
of course, vary according to circumstances. When the digestive 
system is out of order, it must be improved by alterative medicines, 
and perhaps gentle aperients ; but nothing in the shape of drastic 
purgatives should ever be administered to scrofulous subjects. The 
improvement we want to effect in the digestive system is, the esta- 
blishment of a good appetite and digestion ; and this will, in most 
cases, be done, with greatest certainty, by preventing errors in diet, 
giving a sufficient quantity of light nutritious food, partly of the 
animal kind; but never oppressing the stomach: when wine or 
malt liquors can be taken without exciting fever, they should be 
allowed ; but with children such articles are seldom required, and 
often do harm by their stimulant effects. Constant exercise, and 
free exposure to the air, and solar influence, but with a sufficiency 
of warm clothing, are essentials in the treatment of scrofula ; and if 
residence near the sea during the summer months, or short sea- 
voyages under comfortable circumstances, can be accomplished, much 
good may be expected to result. Residence in a mild and equable 
climate during the winter, is also desirable ; but very warm latitudes 
are not suitable for the scrofulous, and the want of many British 
comforts (as fires, comfortable beds, well-aired linen, &c), incident 
to a residence on the Continent, renders a removal to the southern 
parts of Europe a matter of very questionable prudence with persons 
suffering from these disorders. 

As to medicines, we know of none that possess specific antistru- 
mous properties ; and in addition to the mild alteratives already 
alluded to, we would only recommend a trial of such as are con- 
sidered to possess tonic properties, keeping a careful watch, however, 
over their effects, and never pushing them in the hope of their being 
specific cures, after they have appeared to disagree with the system. 



346 CONSTITUTIONAL DISEASES. 

The tonic which we have found most beneficial, and approaching 
nearest to a specific, is certainly iodine ; and this we would give in 
almost every case of scrofula, under the restrictions and in the mode 
recommended at p. 99.* Sarsaparilla will also be found of service, 
and may be given in conjunction with iodine ; as may also the light 
bitters when the state of the stomach requires treatment. As for the 
numerous specifics recommended in this disease, e. g., muriate of 
baryta, hemlock, iron, &c., we consider them to possess no more 
peculiar virtues than as they may happen to have tonic, or anodyne, 
or the like qualities, which may be useful in particular cases.t 

Local Treatment of Scrofula. — When scrofulous glands enlarge 
slowly and remain indolent, we believe it is better to use no local treat- 
ment, and especially to avoid exciting them by frictions with greasy sub- 
stances. We cannot have much hope of dispersing them by such 
means ; and if we could do so, without at the same time changing the 
scrofulous disposition in the constitution, there is reason to fear that, by 
removing what furnishes a sort of counter-irritation upon the external 
surface, we may be only favouring the development of the disease 
in some internal organ. When there is much pain or irritation in 
the tumour, we may have occasion to apply a leech or two, and use 

* The use of ioduretted baths has been much recommended by M. Lugo!, in the 
treatment of scrofula. We give his formula for baths for children between four and 
seven years of age: 



Hydriodate of Potash. 

Troy grains. 

60 to 72. 



Water. Iodine. 

Quarts. Troy grains. 

36. 30 to 36. 

f In a letter lately addressed to the Royal Academy of Medicine, of Paris, by M. 
Coster, the virtues of iron, as a preventive of the development of scrofula, are highly 
extolled. Two years ago, M. C. placed a number of dogs, rabbits, &c, in the cir- 
cumstances most favourable to the development of the scrofulous diathesis. Thus, 
many of the unfortunate animals were shut up in dungeons, without light, or space 
for motion, and exposed to a moist cold by means of wet sponges which were hung 
up in the cages. Some of the animals placed in these conditions, were fed on their 
ordinary diet; others were fed with ferruginous bread, containing half an ounce of 
carbonate of iron, to the pound. All the former became ill, the greater part tuber- 
culous, but not one of those fed on bread containing iron presented a trace of tuber- 
cles.— Bull, de VAcad. Jan. 31, 1840. [Note to 3d Edition.] 

M. Coster has since published his Experimental Researches on the generation 
and prophylaxis of tubercular diseases at greater length (see Gazette des Hospitaux, 
and translation in the Medical Press, vol. vi. p. 247). The views of JM. C. regarding 
the nature of scrofula are very similar to those we have put forward above. He 
considers the disease to be constitutional, and the result of a special organisation, 
either hereditary or acquired. "Tubercles," he correctly observes, " wherever 
situated, do not constitute the disease; they are but the expression, the manifesta- 
tion of a pathological disposition, so universal that it influences every molecule of 
the system, communicating to the entire economy, as to each of its constituent 
atoms, a mode of existence peculiar to itself, and often cognisable in the physical 
and moral condition of the individual." The intimate nature of this pathological 
disposition M. C. does not profess to explain, nor does he offer any theory to ac- 
count for the operation of iron in modifying it. We confess, the moderation and 
soundness of his arguments, as well as the detail of his experiments, and the few 
trials of his plan which we have had an opportunity of making, all combine to in- 
duce us to doubt the correctness of our former opinion as to the non-specific proper- 
ties of iron. M. Coster has, to say the least, made a case to warrant its careful and 
extensive trial, both as a preventive and curative agent. [Note to 4th Edition.] 



SCROFULA. 347 

emollient warm applications, for the purpose of relieving the tension. 
If matter be formed, it becomes a question whether or not an opening 
should be made for its escape. We believe this should not be done 
unless there is more than ordinary pain or tension, or the skin is mani- 
festly on the point of bursting. It is hoped by some that an early 
opening may be the means of preventing any unsightly scar; but it 
does not always do so ; and on the other hand, large tumours 
have been altogether absorbed without breaking, even after the for- 
mation of matter. 

After the abscess has been opened or has burst, if the discharge be 
considerable, we may cover it, for a day or two, with a poultice, and 
subsequently dress it with a bit of dry lint or finely-carded cotton, 
avoiding all greasy applications. The ulcer when indolent, as it usu- 
ally is, may be stimulated by touching its edges with nitrate of silver ; 
and if irritable, the same treatment, followed by a poultice of bread 
and water, or hemlock leaves, or sea- weed, will be found serviceable. 
The healing of these ulcers is commonly very tedious, and will not 
be perfectly accomplished unless an improvement is effected in the 
constitution ; or scrofulous disease breaks out elsewhere. 

After the ulcer has healed, a hard tumour will sometimes remain ; 
and if this be perfectly free from pain, or other sign of irritation, we may 
attempt its removal by the employment of small blisters, or frictions 
with discutient ointments. It is at this time that the different oint- 
ments of iodine may be safely used ; but if any pain or irritation 
arise, they should at once be discontinued. 

In treating scrofulous ophthalmia, much attention should be directed 
to the state of the constitution ; but local management will also be 
found of considerable importance. In the first place, a broad, green 
silk shade should be placed upon the patient, in such a way as to 
stand out well from the forehead, and admit the access of air to the 
eyes, while it intercepts the direct rays of light. This management 
of the shade is of great consequence ; as those usually employed, 
which are small and lie close to the eyes, do more harm than good. 
When there is much redness or pain, a poultice of bread and cold 
water, or of alum curd, enclosed in a muslin bag, should be placed 
over theclosed eye atnight. The best eye water is asolution of sulphate 
of zinc, or alum (three or four grains to the ounce) in rose water. If 
the lids stick together at night, much relief will be afforded by 
anointing them at bed-time with a small portion of dilute citrine 
ointment, or of oxide of zinc ointment, made with five grains ot the 
oxide to two drachms of lard, and with the addition of ten drops 01 

a VheTthe affection is indolent, small blisters behind the ears will 
often be of service. If the conjunctiva becomes granular m old cases, 
the application of caustics will be required, as the sulphate of copper, 

"SSer, nothing is done, if we do not improve Ohe state 
of the wstem bv the general means already laid down. We have 
in a ver™t number of instances, tried the experiment of treating 
the general health alone, using nothing local except the shade and a 



348 CONSTITUTIONAL DISEASES. 

poultice of cold bread and water ; and we are certainly of opinion 
that a greater number of cases will be cured in this way, than if the 
most careful local treatment were combined. We have not unfre- 
quently seen ulcers, and even considerable opacities of the cornea, 
disappear altogether under the use of iodine, without any local treat- 
ment whatsoever. 

Scrofulous disease of the ear requires no direct local treatment, 
except cleanliness ; but will often be benefited by exciting coun- 
ter-irritation behind the ear; the best way to do which is, to place a 
piece of woollen thread, smeared with blistering ointment, in the 
angle between the ear and the scalp. 

In scrofulous discharges from the vagina in children, we have re- 
peatedly tried stimulant and astringent lotions and injections, without 
effect. We believe they can be efficiently treated only by general 
means. 

II. RICKETS (RACHITIS). 

This disease, which is now, happily, becoming rare, was once so 
prevalent in these countries as to be termed the English disease, a 
name {Die Englische Krankheit) which it still retains among the 
Germans. 

It does not affect the young infant, but commonly appears about 
the period of the first dentition, — at least, its effects become then, 
for the first time, manifest, when the child commences to support the 
weight of its body upon its limbs. 

Symptoms. — Before any local characteristics of the disease make 
their appearance, the child's health will be observed to be deranged : 
it is peevish and languid ; the skin becomes dry and rough ; the flesh 
soft and flabby ; the countenance pallid and delicate ; the appetite 
uncertain, and occasionally depraved (unnatural food being sought 
for) ; the digestion is at the same time impaired, the bowels being 
irregular, and the stools and urine unhealthy in their appearance ; 
the abdomen is large, while the rest of the body and the limbs be- 
come emaciated. Along with these symptoms, a general febrile 
excitement is present, similar to that which has been already de- 
scribed under the name of remittent fever, and which, in the last 
section, has been named tuberculous fever. 

After these symptoms have been manifesting themselves for some 
time, the head will be observed to be unnaturally large, and the 
forehead prominent, while a defective ossification of the bones of the 
head will be proved by the open state of the fontanelles and sutures. 
The ends of the long bones at the ankles and wrists become swollen 
into knobs, which seem larger than they really are from the contrast 
with the shrunken limbs ; the sternal ends of the ribs may be also 
enlarged and spongy. That the bones are softer than natural, and 
incapable of supporting the weight of the body, or the action of mus- 
cles, is shown by the bending of the legs, thighs, and arms, and nar- 
rowing of the chest by the straightening of the ribs and projection of 
the sternum forwards. As the disease goes on, the pelvis and spine 
partake in the deformity, which may be carried to such a pitch as to 



RACHITIS. 34 9 

destroy life by interrupting the performance of the functions of the 
different viscera. The teeth also share in the general disease of the 
osseous system, coming out slowly, and prematurely suffering decay. 

It has been observed, that the mental faculties of ricketty children 
are, usually, quick and precocious ; but this is not at all uniformly 
so, and is probably no characteristic of the disease being explainable 
by the greater degree of attention likely to be paid, by its adult rela- 
tives, to the conversation of a delicate child, which is unable to join 
in the active sports of younger companions. A species of acute rickets 
has been noticed by authors, in which all the bones of the skeleton 
are said to have become softened in the space of a few weeks. 

Pathology. — The immediate cause of rickets is a deficiency in 
the earthy matter of the bones, which consequently do not possess 
the natural and requisite firmness. " Dr. John Davy found 100 parts 
of the dry tibia of a healthy subject of fifteen, to yield 46-4 of animal 
matter, and 53-6 of earthy ; while the same quantity of the dry tibia 
of a ricketty child contain 74 parts of animal, and 26 of earthy sub- 
stance/'* The various marks of disease in the cavities and viscera, 
which are found in the bodies of those who die ricketty, are merely 
accidental, and not to be considered as in any way essential to the 
disease. 

The remote cause of rickets are identical with those which pro- 
duce scrofula ; so much so, that by some it is considered as merely 
a form of that disease. It certainly is often combined with unequi- 
vocal marks of a scrofulous diathesis, and to make any difference in 
the general pathology of the two affections is probably but disputing 
about words. Bad nursing, unhealthy, ill-ventilated, damp dwell- 
ings, deficiencies in cleanliness, food, exercise and exposure to light 
and air — anything, in fact, which prevents a healthy nutrition, may 
produce rickets. It appears also to be endemic in certain localities, 
and to be sometimes transmitted by hereditary descent. 

Diagnosis. — There can be no mistake about the disease, when 
its local characters appear. Its early symptoms, however, may be 
similar to those of tabes mesenterica, or simple remittent fever, and 
can only be determined to belong to rickets, by the result. 

Prognosis.— This is favourable when the disease is noticed early, 
and the cause admits of being removed. Danger is to be appre- 
hended when the deformity is so considerable as to impede any of 
the vital functions ; and even if it does not reach this extent, it may 
be sufficient to cause a life of protracted misery, and liability to dis- 
ease About the age of puberty, a marked improvement often takes 
place in the health of ricketty persons ; and in those who, with an 
originally healthy constitution, have been subjected to the disease 
bv bad nursing, a most surprising improvement will often take place 
in the form of the limbs, during recovery. Of course, any disease 
affectin- a child while in a ricketty condition may be expected to be 
particularly severe, in consequence of the deficiency of strength in 
the general system. 

* Cyc. Pract. Med. Art. Rickets, 
30 



350 CONSTITUTIONAL DISEASES. 

Treatment. — We have little to say, under this head, beyond 
what we have already said respecting the treatment of scrofula, and 
in the chapters upon the Management and Education of Children. 
Attention similar to that recommended on those occasions must be 
paid to the ricketty child, with the view of improving its health, 
which is the great principle to be followed out in the preventive or 
remedial treatment of rickets.* Any symptoms of fever, derange- 
ment of the bowels, &c, which attend, must be met by suitable 
means ; and during the treatment we shall frequently have occasion 
to employ gentle, alterative aperients. When the digestive system 
has been set to rights, tonics, both internal and external, will be re- 
quired : among the latter, the tepid salt water bath, and friction will 
generally prove serviceable ; and among the former, iodine and the 
different preparations of iron hold the first place. For the modes 
of administering these medicines, we must refer to the chapter on 
Therapeutics. 

In holding and carrying a ricketty child, the greatest attention 
should be pain to the avoidance or undue pressure upon any part, 
especially the chest. It must be remembered that the bones are in 
a flexible and pliant condition, and that pressure carelessly continued 
in the same situation, will be very likely to alter their shape. When 
recovery is taking place, and the child is sufficiently old, well-regu- 
lated gymnastic exercises will often produce very good effects in ex- 
panding the chest, and straightening the limbs and spine ; but they 
should be used very cautiously, and always with due regard to the 
delicate health and impaired strength of the patient. Dupuytren was 
in the habit of placing the child with a deformed chest, with its back 
against a flat resisting body, and then pressing with the expanded 
palm of the hand upon the sternum, so as to flatten the thorax from 
before backwards, and increase the convexity of the ribs from side 
to side. By repeating this practice from day to day, it is possible to 
effect much improvement in the shape of the chest ; but force suffi- 
cient to cause pain should never be employed. All instruments for 
straightening the limbs, or supporting the spine, are worse than 
useless, as they prevent the action and development of the muscles, 
which afford the only true means of restoring strength and symmetry. 

III. SYPHILIS. 

The venereal disease may be communicated to the young child in 
three ways: — 1st, the fcetusmay be contaminated, while yet in the womb 
of its mother ; 2d, the infant may receive infection from the nipple of 
a diseased nurse ; and, 3d, it may be infected during its birth, the 

* Ricketty children sometimes show a remarkable fondness for common salt, 
which should be indulged to a reasonable extent. This reminds us of having 
omitted, in speaking of the food of children, to dwell upon the necessity and advan- 
tage of giving a sufficient supply of this condiment. Sufficient salt should always 
be put in the broths, and given with the animal food allowed to children, as it con- 
tributes much to the healthy performance of digestion, and is also a powerful pre- 
ventive of intestinal worms. 



s 



SYPHILIS. 351 



mother at the time labouring under primary symptoms of the disease. 
By most authors it has been supposed, that the two latter are the 
only modes by which the child can be infected ; but, strange as it 
may appear, the first mentioned has been, in our experience (which 
has not been inconsiderable), by far the most usual ; and we have 
not in our recollection any case decidedly proving the occurrence of 
the third. Whether or not this is explainable by the supposition of 
Jahn, that the vermx caseosa effectually prevents contamination by 
the skin, we shall not at present attempt to decide. 

Transmission by the nipple of the nurse we have frequently ob- 
served, and have known a whole family to be infected in this way, — 
the nurse having first received the disease from the mouth of a 
syphilitic nurseling. The most ordinary manner, however, in which 
syphilis is communicated to an infant, is by the first mode ; and it 
happens, commonly, in one of the following ways. One or both 
parents may have the disease at the time of the conception of the 
child, or they may have had it previously, and perhaps, at the period 
in question, present no sign of ill-health whatsoever. Under either 
of these circumstances, a child maybe born, apparently healthy, and 
continue so for an uncertain period, (varying from a fortnight to 
five or six months.) when marks of syphilis may show themselves : 
the most usual period for the disease to appear is, according to our 
experience, from the third to the fifth week. In this way the symp- 
toms may be developed, in several successive children of the same 
parents ; but usually, such cases are alternated with miscarriages, or 
premature births of children, dead, and covered with syphilitic erup- 
tion ; or all these occurrences may take place in the same family : 
for example, a woman may miscarry once or twice ; may then pro- 
duce a dead syphilitic child ; and subsequently give birth to one, 
apparently healthy, but showing disease when it has attained the 
age of four or five weeks. There is no regular succession in the 
occurrence of these different events, as they indifferently precede or 
follow each other. 

During the whole period of the production of these diseased 
children, both parents may appear perfectly healthy, and one of them 
may never have had any sign of the disease. We have in our 
recollection many instances in which miscarriages, premature births, 
and syphilitic children have continued to succeed each other, although 
the mother had been always healthy, and the father had no trace of 
disease, perhaps, for years before his marriage. We have now be- 
fore us, notes of the case of a syphilitic child, whose mother had been 
infected by a former husband, and, to all appearance, cured, five 
years before its birth, — the father of the child (her second husband) 
being in good health. Our experience would enable us to adduce 
many curious facts, bearing upon this subject, which, however, would 
be unsuitable in the present work ; and we shall now proceed to 
consider, 

The Symptoms. — We have stated that children may suffer from 
syphilis, while yet in the mother's womb ; in which case they are 
generally born premature and dead, often putrid. The appearances 
on the body of the child are not generally of a decided pathogno- 



3 52 CONSTITUTIONAL DISEASES. 

monic character; we have seen an eruption of copper-coloured 
blotches ; but more usually there is merely a desquamation of the 
entire cuticle. When the child is dead, it has commonly been so for 
some weeks before birth, and has consequently become so putrid as 
to prevent our recognising any marks except those of decomposition. 
We have not, therefore, in the mere fact of the birth of dead and 
putrid children, evidence sufficient to enable us to pronounce upon 
the existence of a syphilitic taint in the constitution of the parents ; 
and, unless the history throws distinct light upon the case, it can 
only be satisfactorily cleared up by the birth of a living child, and its 
subsequently showing symptoms of syphilis. Under these circum- 
stances, the child appears healthy for an uncertain period (from a 
fortnight to five or six months) after birth. The first distinct symp- 
tom usually is the occurrence of a peculiar mode of breathing through 
the nose, known by nurses as the snuffles. At the commencement, 
this is attributed to cold, and seldom attended to until the eruption 
appears : in the interim, however, the child's health is much affected, 
and without any apparent reason. It has no bowel complaint, and 
is not undergoing dentition, but yet wastes away, and is feverish, 
fretful, and pallid. In about a fortnight, an eruption comes out 
rather suddenly, at first upon the lower extremities and buttocks, 
and subsequently upon the face and body. 

The practitioner seldom sees the child until this eruption has been 
for some time in existence, and has changed from its original charac- 
ters. It appears, however, first in the form of copper-coloured 
blotches, about the size of a split pea, and slightly raised above the 
level of the skin ; these are in a slight degree moist upon the surface, 
and, in situations exposed to the air, they soon become scaly, and 
subsequently, are converted into dark-yellowish scabs. Where por- 
tions of skin are naturally in contact, as between the buttocks, in the 
wrinkles of the neck, &c, scales are not formed — but raised, condy- 
lomatous sores. As the disease advances, the skin, in the interspaces 
between the scabs, becomes, throughout, of a copper colour ; and 
perpendicular fissures are formed in the lips, giving the mouth a very 
peculiar and characteristic appearance, which cannot be verbally 
described, but, to those familiar with the disease, is in itself diagnostic 
of its real nature. The voice at this period becomes feeble and 
stridulous ; the inside of the mouth often covered with aphthse ; 
extreme emaciation attends ; and, if medical aid be not afforded, the 
child is reduced to a state of excessive debility, and dies, covered 
with disgusting scabs and ulcerations. 

Such is the ordinary course of the disease ; and so far as we have 
observed it, the syphilis of children presents little variety of form. 
In one case, we saw well-marked syphilitic iritis in a child about a 
year old, whose father had at the time a tubercular eruption ; the 
mother stated herself never to have had any syphilitic complaint. 

Syphilis of children may be, to all appearance, cured by treat- 
ment, and will again return : this may occur several times, at inter- 
vals of a month or two, each relapse being milder than the preceding 
one, until, at length, the taint is worn out of the system. 

When the infection has been communicated in the second mode, 



SYPHILIS. 353 



viz., from sores upon the nipple of the nurse, ulcers will, in the first 
instance, be formed in the mouth of the child, but subsequently the 
characters are similar to those we have just described. The ulcers 
in the mouth are often overlooked, or considered as aphthous : we 
are not able to assign to them any characteristic marks whereby they 
may be diagnosed. 

The Diagnosis of the disease is to be derived partly from its his- 
tory ; but in investigating this, the greatest caution is required, as a 
hint of any suspicion upon the subject might, in many instances be 
productive of the most unhappy domestic results. The tact of the 
physician will therefore be called into play, for the purpose of elicit- 
ing the information he requires, without committing himself to an 
opinion, or exciting unpleasant suspicions in the minds or those with 
whom he is dealing. To persons experienced in the management 
of the disease, the characters of the eruption, as just described, will 
usually be sufficient to declare its nature, and obviate the necessity 
for minute inquiries into its history ; but knowledge of this kind can- 
not be acquired, except by long-continued personal observation of 
patients. The snuffles of syphilis have nothing at first to distinguish 
them from those of common catarrh ; and in this stage it cannot be 
diagnosed, except by a knowledge of its having previously occurred 
with other children of the same family. The disease with which the 
eruption is most likely to be confounded is common itch, which, in 
the delicate skin of the child, may assume a frightfully severe form. 
It is to be known from syphilis by its pustular character, by the 
itchiness which it occasions, and by the absence of the copper colour 
of the skin, and the peculiar fissured appearance of the mouth. Itch 
is also commonly communicated to the attendants of the child, in 
whom its characters will be too well marked to admit of any mis- 
take : and by an observation of this circumstance, the diagnosis will 
be often much assisted. 

The Prognosis is always favourable, when the case is seen early 
and properly treated ; few diseases being more under the influence of 
medicine. If left to itself, however, syphilis infantum is certainly fatal. 
We are also to recollect that even when treated in the most judicious 
manner, it is liable to relapse, perhaps more than once, after an appa- 
rently complete cure. 

The Treatment is exceedingly simple, — mercury being always 
required, and when judiciously exhibited, seldom failing to produce 
a beneficial effect. A question has arisen as to the propriety of giving 
mercury directly to the child itself, or indirectly through the nurse : 
the former is the plan we always adopt, — the child bearing the 
medicine well, and experience having taught us that the latter method 
alone is not sufficient to effect a cure. 

The expediency of putting the parents under the influence of mer- 
cury, with a view to the prevention of a recurrence of the disease in 
future children, involves several distinct considerations. If either 
parent exhibits unequivocal marks of syphilis, there can be no doubt 
of the propriety of adopting suitable means of cure. Frequently, 
however, we shall find no existing symptoms of the kind ; and then 
30* 



354 CONSTITUTIONAL DISEASES. 

we are to consider, whether it will be advisable to mercurialise one 
or both. If both have been formerly infected, it is our opinion that 
both should take mercury : if one has been affected, and the other 
apparently not, there is more difficulty in the case. If it be the female 
alone who has had the disease, as in the case of the widow whom 
we have already alluded to, we think it will probably be sufficient to 
treat her : but under opposite conditions, we are not so much inclined 
to hope for success from treatment merely of the male. In other 
words, we are inclined to suspect that a taint may be communicated 
to the female parent, without its being rendered manifest by any 
outward marks. The subject, however, is in great obscurity, and 
requires many more observations for its elucidation. 

Our plan of treating a child is, to administer from one to two grains 
of hydrargyrum cum creta, two or three times a day (according to 
the age), until the eruption and snuffles disappear. The child usually 
fattens under this treatment ; and salivation is never produced, at 
least we have never seen it, in a child under three years of age. 
Should the mercury affect the bowels, which sometimes happens, we 
must combine with each dose from half a grain to a grain of Dover's 
powder, or of the powder of chalk and opium. The time required 
for treatment is from six weeks to two or three months, and the medi- 
cine should always be continued for two or three weeks after every 
symptom has disappeared : even when this precaution has been 
observed, the disease may return, and the mercurial treatment must 
be, again and again, resumed. The sores about the anus, and in 
other similar situations, will often be benefited by the application of 
black wash, or of dilute citrine ointment ; and when they become 
very indolent, it may be necessary, towards the termination of the 
treatment, to stimulate them with nitrate of silver, or sulphate of 
copper. 

In addition to the foregoing treatment, when the mother is suckling 
her own child (and, for obvious reasons, it never should be given to 
a strange nurse), it will be well to treat her with alteratives, — as, 
for example, sarsaparilla ; but unless she labours under actual 
syphilitic symptoms, the giving of mercury to her should not be 
thought of until the child is weaned, as by affecting her general 
health, it would be likely to deteriorate her qualities as a nurse. 



IV. PURPURA. 

A form of this affection is not uncommonly met with among the 
children of the poor, in large cities, and has been noticed by Heberden 
in his Commentaries. It has been included by Willan among the ex- 
anthemata ; but the mode of its appearance, without distinct preceding 
fever, as well as its duration and course, sufficiently distinguish it 
from those diseases, with which indeed it has nothing in common, 
except that it engages the cutaneous surface. 

The form of purpura which we have observed in children is that 
denominated by Willan purpura simplex. 

Symptoms, — It appears in the form of purple spots, varying from 



PURPURA. 355 

the size of flea-bites (for which they are often mistaken), to that of 
a shilling, or even larger. These are not elevated above the sur- 
face, but consist of small extravasations of blood in the tissue of the 
skin : they are not productive of any local uneasiness whatsoever. 
The appearance of the spots is not preceded by any distinct febrile 
reaction ; but the child will be always found to have been somewhat 
out of health previously ; it has been pallid and delicate-looking, 
with a quickened pulse, and more or less derangement of the 
bowels ; and frequently the subject, for some time, of an attack of 
remittent fever. Often, the child will be brought to us for some other 
disease, and we shall be the first to notice the purpural appearance, 
which has been previously considered by the parents to be merely 
the effect of flea-bites. Should the disease run on, in consequence 
of injudicious treatment, or of a continued exposure to its original 
cause, slight pressure will produce vibices ; larger extravasations of 
blood will be formed upon the surface ; hemorrhages will take place 
from the various passages, and the case, in short, will become one 
of true purpura hemorrhagica. 

Pathology. — This disease, if not identical with scurvy, is at least 
very analogous to it, and the proximate cause of both is probably 
the same. Into a consideration of this subject, however, involving, 
as it does, the whole dispute between the humoralists and solidists, 
it would be out of place here to enter ; and we shall only mention 
the conditions which we have seen most frequently associated with 
the purpura of children. The subjects of the disease have been 
always, according to our observations, living in situations unhealthy, 
damp, and imperfectly supplied with light and air ; their diet has 
also been scanty, or unsuitable to their age. Dr. Graves justly ob- 
serves,* that he has usually found that such children were fed upon 
salt provisions, as bacon, salted herrings, &c. ; and without making 
any inquiries upon the subject, we shall frequently perceive, by the 
peculiar odour of these patients, that the latter article has been a 
chief constituent of their diet. 

The chief point in the Diagnosis of purpura simplex is, to dis- 
criminate the spots from flea-bites : these latter may be recognised 
by their redder colour, and by the central puncture produced by the 
bite, as well as by their more rapid disappearance from the skin. 

When a suitable dietetic and general treatment can be adopted, 
the disease, if uncomplicated, readily yields ; but purpura always 
indicates a bad state of constitution, and betokens evil, when it occurs 
in the course of other disorders. 

The Treatment must consist less in the administration of medi- 
cines than in the improvement of diet and regimen. In place of tea 
and salted provisions ; milk, fresh meat, and vegetables should con- 
stitute the child's food : it should live in an airy situation, and be 
made to exercise freely in the open air during a large portion of each 
day The surface of the body should be sponged, night and morn- 
ing, with tepid vinegar and water, and the strictest attention paid to 
cleanliness. 

* Dub. Med. Jour. vol. iii. 



356 CONSTITUTIONAL DISEASES. 

With respect to medical treatment, the bowels, if deranged, should, 
in the first instance, be set to rights ; and for this purpose some mild 
alterative aperient (see pp. 126, 127), will usually be required. We 
have sometimes given, with advantage, small doses of quinine with 
the mineral acids ; and Dr. Graves has found benefit to arise from 
the administration of citric acid, to the amount of half a drachm daily. 
Usually, however, attention to the bowels, with regulation of the 
diet, &c, will be sufficient to effect a cure without any further medi- 
cal interference being required. 



V. PEMPHIGUS GANGRENOSUS (BURNT HOLES). 

A variety of pemphigus to which the epithet gangrenosus has 
been applied by Dr. Stokes the elder,* is not uncommonly met with 
among children, and constitutes a very dangerous disease. It occurs 
usually within the first five years of life, chiefly among the children 
of the poor, who live in damp, unhealthy situations ; and it sometimes 
assumes an epidemic character. 

Our account of the Symptoms we shall take, in a good measure, 
from the essay of Dr. Stokes, who first accurately described them, 
adding any thing which our own experience may suggest. " The 
approach of this disorder is sometimes, though rarely, denoted by a 
livid suffusion, like that of erysipelas, slightly elevated. It more fre- 
quently happens, however, that the complaint comes on in perfect 
health. One or more vesicles appear, mostly larger than the best 
distinct small-pox : these increase for two or three days, burst, and 
discharge a thin fluid, having a disagreeable smell, limpid in most 
cases, sometimes whitish, and sometimes yellowish ; the latter less 
dangerous : usually, the weaker the child's constitution is, the thinner 
is the matter.f Before or after breaking, the vesicles run together ; 
the sore becomes painful, with loss of substance, and a thin, fetid, 
ichorous discharge ; the edges of the ulcer are undermined, and it 
spreads quickly." We have sometimes observed the sore to put on 
a very peculiar appearance, being clean, but perfectly destitute of 
granulations, without any surrounding inflammation, and seeming 
exactly as if a portion had been scooped out of the sound skin with 
a sharp gouge. The surface of the sore, is, in other cases, livid and 
sloughy, true gangrene actually taking place in it. 

" The most usual seats of the disease are, behind the ears, some- 
times on the hands or feet, on the private parts, (seldom on the arm- 
pit,) the breast, folds of the thighs, lower belly, on the inside of 
the mouth or lips. If the sores are behind the ears, they destroy 
the connection of the posterior cartilage with the cranium ; they 
spread to the meatus auditorius : to the eyes, the sight of which 
seemed, in a few cases, to have been destroyed one or two days be- 
fore death ; and they sometimes extend to the vertex. 

* Dub. Med. and Phys. Essays, vol. i. Dublin, 1808. 

f Dr. M'Adam, in one case, found this matter so acrid as to corrode sound skin 
upon which it had dropped. See Dub. Med. and Phys. Essays, vol. i. 1803. 



BURNT HOLES. 



357 



"The constitutional disturbance, that accompanies this disease, 
seems principally the effect of irritation. When the vesicles burst 
the child begins to grow peevish and fretful, pale, loses its appetite 
and the flesh becomes remarkably flabby. The periods of the dis- 
order are not very regular; but it often 'happens, about the eighth 
day, that the pulse sinks, the lividity spreads over the whole sore 
the fetor and discharge increase greatly. The smell is so strong as 
often to be perceivable at a distance from the bed. The discharge 
in one case, where the ulcers affected the arm-pits and breasts, was 
such that the linen was completely loaded several times a day. 

" Death takes place about the tenth or twelfth day, often preceded 
by convulsions, sometimes by extreme debility. Patients are apt to 
relapse soon after the sores are skinned over. 

" The causes of this malady are rather obscure. It seems exclu- 
sively confined to children. Dr. M'Donnell saw twenty cases before 
the year 1795 ; all the patients were under four years old. Dr. 
Spear observed, that it was confined to children from the age of 
three months to that of five years ; but it has been observed, near 
Dublin, in children of nine years old. It attacks the finest children 
in preference ;* the children of the poor more frequently than those 
of the affluent ; and those who live in damp situations seem more 
peculiarly subject to it than others. The disease is more prevalent 
in summer than in winter. It appears to be infectious, though ob- 
scurely so, in general ; but in the year 1800, Dr. Spear observed it 
to spread epidemically." 

Diagnosis. — The eruption of pemphigus at the commencement 
bears some resemblance to that of varicella ; but the progress of the 
vesicles, in the former case, to ulceration, and in the latter to desicca- 
tion, soon establishes the difference. Excoriations behind the ears, 
and in the angle between the thigh and pudenda, occasionally pro- 
duce very troublesome sores ; but they are to be distinguished from 
pemphigus by their origin, not in vesicles, but in simple chafing of 
the skin ; neither are they so rapid in their course, nor attended with 
such severe contitutional disturbance. 

The Prognosis in pemphigus gangrenosus is unfavourable, and 
the more so in proportion to the amount of constitutional disorder. 
The most unfavourable characters are, rapid spreading of the sores, 
and supervention of gangrene ; also paleness and fetor of the dis- 
charge. 

The Treatment of this disease has usually been directed princi- 
pally to its local manifestations ; and Dr. Stokes, with considerable 
trouble, procured and published the particulars of the composition of 
an ointment, which appears to have been extensively and success- 
fully employed in its management by the Irish peasantry. The 
essential ingredient in this ointment, Dr. S. found to be the leaves 
of the scrofularia nodosa (great Jigwort,phogr am, or rose noble) — 
an officinal preparation of which has been latterly introduced into 

* This does not accord with our own experience, as we have usually seen the 
disease in ill-fed, delicate subjects. 



358 CONSTITUTIONAL DISEASES. 

the Dublin Pharmacopoeia. His practice was, in the first instance, 
to apply a carrot poultice, or one formed of porter and oatmeal, to 
the sores. After about eight hours, this was to be removed, the 
parts affected very gently wiped with lint, and the scrofularia oint- 
ment, previously melted to the consistence of honey, applied by a soft 
feather, and with the utmost gentleness, to the whole surface of the 
sore. After smearing the ulcer with the ointment, it should be 
dressed with the same ointment, with the addition of one-eighth part 
of wax. The dressing should be repeated, in severe cases, every 
fourth or sixth hour. With respect to general treatment, Dr. S. says, 
" I believe it to be necessary that the child's bowels should be kept 
open. I also direct the internal use of yeast, which I am of opinion 
is of service, but cannot decidedly prove it to be so." 

We entirely concur in the foregoing plan of local treatment, and 
have found considerable advantage in the employment of the scrofu- 
laria ointment ; but our own experience would decidedly lead us to 
the adoption of a very careful general treatment. Change of locality, 
and free ventilation of the patient's apartment, should, if possible, 
be effected at the very commencement. The bowels should be regu- 
lated by alterative aperients, which commonly bring away dark- 
coloured and offensive stools. The diet should be nutritious, but not 
stimulating ; and if the child be suckling, a fresh and healthy nurse 
should be procured. As soon as the bowels have been set to rights, 
we commonly administer quinine ; and if there be no diarrhoea, we 
may combine it with one of the mineral acids. 

We have seen a comparatively chronic form of the disease among 
children, in which we have found the most decided benefit to attend 
upon the employment of iodine. 



A disease has been described by Mr. Kinder Wood, in the 7th vol. 
of the Med. Chir. Transactions, under the name of " a very fatal 
affection of the pudendum of female children," which appears to us 
to be merely a form of pemphigus infantilis, and to require treat- 
ment founded on principles precisely similar to those we have just 
laid down. All Mr. Wood's cases occurred between the first and 
sixth years ; and of twelve which he saw, only two recovered. One 
of the most remarkable symptoms which he observed, and which we 
may consider to be peculiar to the affection of the pudendum, was 
retention of urine. This appeared to be in a great measure volun- 
tary, the patient being unwilling to encounter the pain of making an 
attempt at passing water : it accordingly required a vigilant atten- 
tion on the part of the attendants. In a fatal case quoted by Mr. 
Wood, " the abdominal and thoracic viscera were found to have 
been free from disease." 



SCALDING OR CHAFING. 359 



CHAPTER XIV. 

DISEASES OF THE SKIN. 

The cutaneous system, during the periods of infancy and childhood, 
is subject, as in the adult, to many important forms of disease. Seve- 
ral of these we have already considered under other heads, and of 
those remaining unnoticed there are a considerable number which, 
presenting no remarkable peculiarities in the young subject, require 
no special attention in the present work. It would also be, mani- 
festly, out of place to enter at any length into a consideration of the 
difficult and obscure subject of cutaneous diseases, or to attempt even 
a sketch of the manifold classifications invented by authors, with the 
design, hitherto unaccomplished, of introducing order and perspicuity 
into this intricate branch of medicine. We shall, therefore, content 
ourselves with a few short practical sketches of certain affections of 
the skin necessary to be understood by the child's physician, either 
from the frequency of their occurrence, or the peculiarities of their 
diagnosis or treatment during the early stages of life. Having laid 
down this limited plan for our guidance, we shall not adhere to any 
particular nosological system, but without mystifying ourselves and 
our readers by attempts to ascertain the various meanings attached 
to the same appellations by different authors, we shall endeavour to 
attain intelligibility by the employment, as far as possible, of terms of 
a general signification and popular use. 

I. ERYTHEMA INTERTRIGO (SCALDING OR CHAFING). 

This affection, which is a species of exanthem, very frequently 
occurs in infants and young children, showing itself on the groins, 
upper part of the thighs, scrotum, neck, between the buttocks, behind 
the ears, and on other parts where opposite surfaces of the skin are 
in continual contact, or subject to friction, being often occasioned, in 
the first instance, by neglect on the part of the nurse, and inattention 
to cleanliness. 

It appears in the form of red blotches, irregular in shape, not defi- 
nitely circumscribed, varying much in size, and commonly lasting 
from eight to twelve days. There is but little general fever ; but the 
child is fretful, and the local inflammation is sometimes considerable, 
being accompanied by severe itching, and the exudation of a faint- 
smelling sero-purulent fluid. If the affection continues unrelieved, 
the skin becomes hard and chapped, and troublesome excoriations 
follow A form of erythema may sometimes be seen upon the cheeks 
of children during teething; at first appearing merely as a bright red 
blush, and subsequently leaving the skin rough and fretted. 

The Diagnosis of erythema intertrigo is not difficult Erysipelas 
and syphilis are the diseases with which it is most likely to be con- 



360 DISEASES OF THE SKIN. 

founded ; but from the former it may be distinguished by its super- 
ficial character, and by the absence of any severe constitutional dis- 
turbance. Its common seat about the groins and buttocks may cause 
it to bear some slight resemblance to syphilis ; but the coppery colour 
of the latter, together with the snuffles and other symptoms belonging 
to it, furnish abundant means of discrimination. 

The treatment of this affection is very simple, consisting almost 
entirely in a removal of the exciting cause by strict attention to clean- 
liness, and keeping the parts dry. When the inflammation is con- 
siderable, fomentations with warm water, or decoction of chamo- 
mile flowers, will be useful. When the discharge is troublesome, 
the parts may be washed, two or three times daily, with tepid spirits 
and water, and subsequently dusted over with finely powdered starch. 
The administration of a mild alterative aperient, as the powder of 
rhubarb and magnesia (p. 126) will usually complete the cure. 

II. URTICARIA (NETTLE RASH). 

Young children are not unfrequently affected with this eruption, 
which, though unimportant in its own nature, may, by the sudden- 
ness of its attack, occasion considerable alarm. It is most likely to 
occur in hot weather, and often seizes children during sleep, from 
which they then awake restless and screaming. Upon examination, 
the body and lower limbs will be found covered with raised patches 
or wheals of irregular shape and pale colour, resembling those 
caused by the stinging of nettles, and accompanied by excessive 
itchiness. It may often be traced, as in adults, to some irregularity of 
diet. 

Nettle rash is an affection of very trifling importance, and in the 
child usually requires but little treatment. A tepid bath will relieve 
the itchiness and heat, and a slight aperient will commonly remove 
the exciting cause of the disease. 

III. SCABIES (ITCH). 

This disgusting disease is very frequently met with in young 
infants, whose tender skins are extremely susceptible of the infection. 
Its nature is, however, often mistaken, and it is chiefly upon this 
account that we are led to notice it. Itch is commonly communi- 
cated to young infants from the hands or breast of the nurse, and it, 
therefore, first appears upon the buttocks and lower limbs, or upon 
the back of the neck, the hands often continuing completely free 
from spots. Owing to the delicacy of the skin it is attended with 
much more inflammation than in adults, and sooner assumes a pus- 
tular character. The pustules, also, break earlier, and thus give 
rise to larger and more doubtful looking ulcers and scabs. These 
circumstances, together with the severe constitutional disturbance 
which itch often occasions in the young child, frequently perplex and 
deceive the practitioner, and we have not unfrequently known it to 
be mistaken for a syphilitic eruption. 



CRUST A LACTEA. rtfil 

The diagnosis will commonly be made quite clear by an inspec- 
tion of the nurse, on whose skin the true characters of the disease 
may, in almost every instance, be readily recognised. 

The treatment may be disposed of in very few words; it con- 
sists, as in the adult, of the internal and external use of sulphur. 
With children, however, this powerful medicine must be cautiously 
used ; not more than a drachm of the ointment should ever be 
applied at one time, and the application should be made successively 
to different parts of the body. The plan which we adopt is to direct 
a portion of sulphur ointment, about the bulk of a hazel nut, to be 
rubbed, at bedtime, upon a fourth part of the surface of the body, 
and the child to be placed in a tepid bath for ten minutes on the 
succeeding morning. The process is to be repeated, each night, upon 
a different portion of the body, until the eruption has entirely disap- 
peared ; at the same time half a drachm of sulphur electuary should 
be given every second night to more grown children ; but for those 
at the breast it will be sufficient to give the nurse, each night, a tea- 
spoonful of the flower of sulphur. 



IV. CRUSTA LACTEA. 

The disease of which we propose to treat under this name has 
been variously denominated by system-mongers, according to their 
peculiar fancies in the matter of classification. Thus, it is termed, 
by Willan, Porrigo larvalis ; by Bateman, Impetigo larvalis ; by 
Rayer, Eczema impetiginodes; and by others, Tinea muciflua,granu- 
lata, &c, &c. ; but unfortunately by none of these learned appellations 
are we made at all the wiser as to the nature and treatment of the 
affection. 

The eruption usually occurs during teething, and appears to be 
much connected with that process ; it commonly commences on the 
forehead, by the breaking out of a number of small, yellowish pus- 
tules, more or less confluent and crowded together upon a red surface. 
These pustules excite great itchiness, and are quickly broken, dis- 
charging a viscid fluid that subsequently concretes into thin greenish- 
yellow scabs. The scabs are frequently rubbed off, and, when they 
form again, are tinged, of a dark colour by the blood which follows 
the furious scratching of the child. Fresh crops of pustules appear 
around the scabs which quickly extend to the scalp and over the 
face, sometimes covering the latter as with a mask, and justifying 
the epithet larvalis. When the scalp becomes engaged, the lym- 
phatic glands at the back of the neck enlarge and occasionally sup- 
purate. The ears seldom escape, and patches of the eruption will 
also often appear upon the neck and breast ; upon the head, the 
discharge from the pustules is caught by the hair and concretes into 
small, irregular, friable masses, somewhat resembling the bruised 
yolk of a hard-boiled egg. At the termination of the disease, the 
skin of the face remains, for some time, red and tender, but scarcely 
31 



352 DISEASES OF THE SKIN. 

ever retains any permanent marks. Owing to the extreme itchiness, 
and the irritation occasioned by the continual efforts of the child to 
scratch its face and head, sleep will usually be much disturbed, and 
a state of uneasiness and fretfulness kept up : it is, however, often 
wonderful how little the general health may be affected in this dis- 
ease, and how well the process of dentition, and the functions of 
digestion and nutrition may be performed during its continuance. 
Still our observation does not lead us to coincide, unconditionally, 
with Dr. Underwood, who says, he " never saw an infant much 
loaded with it but it-has always been healthy, and cut its teeth re- 
markably well." We have certainly seen it produce severe and 
dangerous constitutional disturbance, although such cases are excep- 
tional, and the prognosis is, in general, highly favourable. This 
disease does not appear to be contagious, although Alibert mentions 
an instance in which it was propagated by inoculation. 

The treatment of crusta lactea should, we think, be of a very 
simple kind. We have little faith in the numerous lotions recom- 
mended by authors, and ointments of all sorts we have invariably 
found to be injurious. In the early stages, when there is considerable 
inflammation, and the discharge is copious and acrid, bathing, several 
times during the day, with tepid water or a decoction of poppy-heads, 
will give relief, and when the scabs are hard and extensive, poultices 
oi linseed meal will be necessary for their removal. The hands of 
the child should be muffled at night, and it should be carefully 
watched in order to prevent it from scratching its face and head, but 
the utmost attention will usually be insufficient for this purpose. 
When the severity of the inflammation has subsided, and the disease 
ceased to spread, we have derived much advantage from lightly 
touching the raw surfaces, from which scabs have been rubbed, with 
a pencil of lunar caustic, or brushing them over with a camel's hair 
pencil moistened in a solution of that substance. This application 
removes the itching more effectually than any other of which we 
are aware, and thus often enables the child to enjoy a night's quiet 
rest. The internal treatment should be such as maybe indicated by 
the state of the general health ; the employment of mild alterative 
aperients combined with antacids (Nos. 27, 28, and 29) will usually 
be productive of much benefit. When the disease becomes chronic, 
tonics will probably be required, among which none is more suitable 
than the hydriodated solution of iodine (No. 10). In this stage we 
have also found the tepid, or, when the season is suitable, the cold 
salt water bath, very serviceable. In every case, the strictest atten- 
tion should be given to the regulation of the diet, and the restriction 
of all articles of a stimulant or acescent character. 



V. HERPES CIRCINNATUS (RINGWORM). 

This affection is very common among children after the period of 
infancy. With some -individuals it is an annual visitant, making its 



SCALD-HEAD. 



363 



appearance, regularly, every spring, during the period of childhood. 
The vesicular ringworm is an eruption of small, globular vesicles 
crowded closely together, and arranged in the form of a ring or 
crescent ; the portion of skin included within the figure is healthy 
and of its natural appearance, and commonly measures from half an 
inch to two inches in diameter. The vesicles are filled with a trans- 
parent fluid, and the skin upon which they are set is of a red colour, 
especially towards the outer margin of the circle. The breaking 
out of the eruption is attended with itching and smarting, which con- 
tinue during its progress. In five or six days, the redness begins to 
disappear, the vesicles become turbid and finally burst, their place 
being then occupied by thin scaly scabs, which desquamate, between 
the 10th or 15th day from the commencement, leaving the skin be- 
neath of a bright red colour. Sometimes the smaller vesicles do not 
burst ; but the fluid within them being absorbed, a slight desquama- 
tion of the cuticle takes place. Several patches of ringworm usually 
appear at the same time, or they may be evolved in succession during 
a period of several weeks ; their most common sites are the forehead, 
backs of the hands and wrists, the ham, and the back part of the 
forearm near the elbow. Very little constitutional disturbance attends 
the eruption, which does not seem to be contagious, although it is 
often seen at the same time upon several individuals in a family or 
school. This, however, may be accounted for by the disposition of 
the disease to appear at a particular season of the year. The name 
of vesicular ringworm, must not lead to its being confounded with 
pustular ringworm of the scalp (porrigo scutulata), which is a dis- 
ease of a very different character and much more troublesome nature. 
The Herpes circinnatus or vesicular ringworm, though troublesome 
from its appearance and itchiness, is seldom followed by any perma- 
nent, disagreeable results. 

The treatment consists in little more than guarding the affected 
part from the ill effects of scratching. At the commencement, the 
best application will be a fold of lint wet with cold water, and covered 
with a piece of oiled silk — the common Avater dressing. Should 
this not relieve the itchiness, the spots may be brushed over with a 
solution of nitrate of silver. Alterative aperients should at the same 
time be given, and, during the process of desquamation, the tepid 
salt water bath should be frequently employed. 



VI. TINEA CAPITIS (SCALD-HEAD).. 

No words can convey a keener satire upon the imperfection of 
the medical art, than would a simple enumeration of the names and 
enkhets invented by various authors for the disease of scald-head, 
and a con ras of that multitudinous catalogue, with the beggar y 
account o haemal knowledge of means whereby we can reasonably 
exnect to accomplish the removal of that distressing affection. Chap- 
ters and volumes have been composed upon this unhappy subject; 



364 DISEASES OF THE SKIN. 

the finest distinctions between the varieties of scabs and sores have 
been pointed out ; the most learned and unintelligible names have 
been constructed from all languages ; the art of the apothecary, and 
the fancy of the quack have been strained for the invention of oint- 
ments, lotions, and depilatories, and yet, we believe, no systematic 
writer, at the present day, points to any line of treatment to which 
we can look with a confident hope of its being sufficient for the cure 
of any particular case of the disease. Still we do not believe tinea 
capitis to be hopelessly incurable ; and we are further of opinion, 
that the obstinacy with which it has hitherto been found to resist 
treatment, has been referable less to its own nature than to the want 
of patience on the part of medical practitioners, and the variety of 
remedial experiments which they have consequently been led to in- 
stitute. In the observations which we now propose to make, we 
shall not attempt to follow out the tedious descriptions of the syste- 
matic writers, or to temovethe obscurity with which their whimsical 
epithets and divisions have enveloped the subject ; but, without enter- 
ing into nice distinctions,shall endeavour to convey a general view of 
the characters of the disease, and thereupon to found rational prin- 
ciples of treatment. 

Tinea Capitis is a disease rather of childhood than of infancy, 
commonly occurring about the sixth or seventh year. It may, how- 
ever, make its appearance at a much earlier age. It is highly conta- 
gious, and is very readily communicated among children using the 
same combs or brushes, or wearing the same head dress, so that 
when once introduced into a school or other assemblage of young 
persons, it is very likely to contaminate almost every individual. 
Besides contagion, there would appear to be other causes that favour 
the production of tinea, and which are well worthy of attention. We 
find, for example, that it is comparatively uncommon in the board- 
ing schools used by the children of the higher classes, while it is a 
very common visitant of institutions in which any considerable num- 
ber of the children of the poor are assembled. When we inquire 
into the circumstances of these assemblages, we shall usually find 
that the children are the offspring of very destitute parents ; that 
they have been neglected and ill fed during infancy, and are conse- 
quently defective in constitution, and often scrofulous. Their habits 
in such institutions, are also, very generally, unfavourable to health; 
they are kept during a great portion of the day in a sedentary pos- 
ture, and in a crowded schoolroom ; their sleeping apartments are 
over filled ; their food ill suited to their tender years, and their cloth- 
ing often insufficient upon some parts of the body, as the head or 
feet ; cleanliness, too, is frequently but superficially practised among 
them. Such are the circumstances under which tinea most com- 
monly appears, and we can scarcely refuse to admit that they 
must be considered as at least among the causes that favour its pro- 
duction. 

The external characters of tinea vary considerably in different 
cases ; such variation, apparently, depending partly upon the dura- 



SCALD-HEAD. one 



tion of the disease, and partly upon the constitution of the patient, 
inus we shall have, in one case, the scalp covered with clusters 
ot minute, oozing, red prominences, some of which are covered with 
ary yellowish scabs, while others are indented with pits or cups filled 
with pus, presenting a honeycombed appearance and exhaling adis- 
agreeable odour, similar to that of the urine of cats. These characters 
nave been described by authors under various names, as porrigo, or 
tinea, favosa or lupinosa ; favus dispersus ; true porrigo, &c. 

In another instance, the scabs will be found to be thick and firm, 
and to assume somewhat of a definite circular shape, whence many 
other names are derived; as porrigo, scutulata; pustular ring- 
worm, favus confer tus, &c. 

Again, when the scabs are united into one firm incrustation, cover- 
ing the head like a cap, the names of tinea Crustacea, porrigo lar- 
valis, and impetigo larvalis, &c, have been applied to the disease ; 
while it is by some termed tinea granulata, when the hairs are 
matted and glued together by the scabs, into separate tufts. 

In a fifth case we may have the discharge less abundant and less 
viscid, in consequence of which the scabs will assume a thin and 
scaly character ; or the discharge may dry into a branny powder 
which can be easily separated from the scalp. In these cases which 
are most common among scrofulous children, the hair falls off in 
patches, and becomes weak and light coloured. When it assumes 
this appearance, the disease has been called indifferently tinea fur- 
fur ans, tinea asbestina, porrigo furfur a cea, ecpyesis porrigo, &c. 

Lastly, as a consequence of tinea, the scalp may become, entirely 
or in part, devoid of hair, the skin being free from ulceration or scab, 
and smooth, shining, and white. This baldness is described by some 
writers as occurring without any previous morbid appearance ; but 
we do not believe this statement to be correct: in most of the cases 
which have fallen under our notice, the loss of hair was known to 
have been preceded by an eruption of pustules, though in some in- 
stances these were so minute as to attract but little attention. It is 
this state which is described in books under the title of alopecia ; 
porrigo deca Ivans ; trichosis area, &c. 

Tinea is always attended with extreme and harassing itchiness, 
which is augmented by the numerous pediculi produced under and 
among the scabs. The severity of the local irritation is generally 
shown by the swelling and inflammation of the lymphatic glands, at 
the nape of the neck, which often suppurate. The cellular tissue 
beneath the scalp will also, in severe and neglected cases, become 
the seat of collections of matter, and the inflammation may extend to 
the periosteum, and even to the bones of the cranium. It is attempt- 
ed to be argued by some writers, that the disease is merely local. 
This opinion we consider to be altogether incorrect ; at all events 
there can be no doubt that if it be not occasioned, it is constantly 
attended by very considerable constitutional disturbance. Rayer 
correctly observes that tinea is often complicated with chronic in- 
flammation of the gastro-intestinal mucous membrane, and that, 
31* 



366 DISEASES OF THE SKIN. 

when it becomes inveterate, the intellectual faculties are frequently- 
diminished in vigour, and a sort of premature old age appears to be 
induced. The nails of the feet and hands sometimes exhibit remark- 
able alterations, increasing in thickness, and becoming rough and 
yellowish in colour. 

It may be collected from what we have already stated, that we 
consider the p?*og?iosis in tinea capitis to be unfavourable. It may, 
however, wear itself out after a continuance of months or even years, 
and it may terminate, by a destruction of the bulbs of the hair, in 
that state of baldness to which we haye just adverted. Our pro- 
gnosis should, nevertheless, refer to the tediousness and obstinacy, 
rather than to the incurability of the disease. Patience and cleanli- 
ness, with attention to the general health are, we believe, the grand 
remedial agents required, and by the employment of these, during 
six months, the late Dr. J. Crampton,* cured a total of twenty-eight 
cases which he treated, together, during that period. 

The treatment of tinea, as it is laid down in the works of syste- 
matic writers is a mere jnmble of empirical experiments: lotions, 
ointments, eseharotics, and depilatories of all kinds, from the decoction 
of flaxseed to the pitch cap, inclusive, have been freely recommended 
and unsparingly used, and each and all have most impartially failed. 
To enter into any discussion with respect to the numberless propo- 
sals of remedies, or even to enumerate them, would lead us far be- 
yond our limits, and that without conveying the least particle of 
useful information to our readers. Those who are curious on the 
subject, we must, therefore, refer to the express works on cutaneous 
diseases, and shall now content ourselves with sketching the plan of 
treatment which appears to us most rational, and which we have 
found to be comparatively, though (we must confess) not absolutely, 
successful. The treatment, then, must be both constitutional and 
local ; the former being directed to there-establishment of the general 
health, by whatever may appear in each case to be the most suitable 
means. In children who have been leading sedentary lives, who 
have been poorly and carelessly fed, and whose digestive systems 
have consequently become disordered, aperients are strongly indi- 
cated, and those of a saline kind will be found to be particularly useful. 
In scrofulous children, much benefit will generally be derived from 
the use of the warm tonic purgatives, as the saline infusion of rhubarb 
(No. 2S), or the aloetic mixture (No. 35). Dr. Crampton recom- 
mends purgatives every second morning ; but we must, of course, 
use our discretion as to the frequency of their repetition, always 
stopping short of exciting any excessive irritation in the intestinal 
canal. In almost every case, we shall find advantage from the em- 
ployment of iodine given in the form of the hydriodated solution 

* We have to acknowledge the great advantages which we derived from a peru- 
sal of the paper of this able and lamented physician, published in the fourth vol. 
of the Transactions of the King and Queen's College of Physicians. In a few 
pages, Dr. Crampton has conveyed more information in an intelligible form, than is 
to be found in all the systematic works taken together. 



SCALD-HEAD. 



(No. 10), and ill doses suited to the age of the child. Should the henatir 
system be materially deranged, alterative doses of mZyZy 
ZK?S2 £ Z5S2&** the *■!■** * Patients wLse 



tatP 3 £*' V he Sk f WiU alrn0St alwa ^ s be in an unhealthy 
state being dry, harsh, and supplied irregularly with heat. In such 



cases no remedial measure is more useful than the warm bath, which 
may be employed every second or third night. While adopting these 
means in whole or in part, as may in each case seem advisable, the 
strictest attention must be paid to the regulation of the diet, which 
should be light, nutritious, and such as we may find from expe- 
rience will agree best with each patient. The clothing also should 
be comiortable, the feet kept warm and dry, and precautions adopted 
lor preventing an irregular distribution of heat throughout the body. 
I he sleeping apartment of the child should be airy, and not over- 
crowded with occupants. 

In conducting the local treatment, the first indication is the removal 
oi the scales and crusts, the presence of which upon the scalp keep it 
in an irritated and filthy condition. The next step must have for its 
object to soothe and mitigate the inflammation under which the diseased 
parts more or less suffer. In pursuance of these indications, then, 
we must at once have the hair taken off by clipping, or shaving when 
that is practicable. The scabs or crusts must next be removed by 
washing with soap and water j or where that will not succeed, by 
poultices of linseed or oat-meal. In some cases the crusts are unusu- 
ally firm and tenacious, and in order to effect their removal we may 
find it necessary to employ, for a few days, poultices made of brown 
soap, reduced to a stiff jelly. When the scabs have been removed 
by this application, the linseed or oat-meal poultice maybe resumed, 
and continued as long as the scalp remains in a morbid condition. 
As the poultice cannot be conveniently used while the patient is 
taking exercise, the best substitute for it, during such periods, 
will be the liniment of lime-water and oil, which may be smeared 
over the head with a brush or feather, and covered with a soft linen 
cloth. Throughout the treatment we need scarcely say that the head 
must be regularly washed with warm soap and water, and the utmost 
attention given to the preservation of cleanliness. 

If the foregoing plan be pursued steadily and with patience, and 
recurred to should relapses (as often happens) take place, it will, in 
many cases, according to our experience, prove successful. Should 
it fail, after a reasonable trial, the practitioner will probably be 
justified in resorting to the depilatories, escharotics,and other severe 
measures, recommended in books, and during their use the disease 
will no doubt sometimes be removed ; we may state, however, that 
Dr. Crampton's twenty-eight cases were treated upon a plan similar 
to that laid down above, during six months, and were all ultimately 
cured. The topical applications tried by Dr. C. at first, all failed ; 
among them were ointments of oxides of mercury, lead, and zinc ; 
of pitch, sulphur, black pepper, and sulphuric acid ; and lotions of 



368 



DISEASES OF THE SKIN. 



almost all the metallic salts. We have ourselves tried most of these 
applications, and some others besides, and have not been much more 
successful in their use than was Dr. Crampton. 

In that variety or termination of tinea capitis, in which the hair 
falls off in patches, leaving the scalp smooth and white, and known 
among authors as alopecia or porrigo decalvans, it becomes a desi- 
deratum to discover some means of promoting a new growth of hair. 
For this purpose a vast variety of applications have been recom- 
mended and tried ; but we must frankly admit that we know of 
none possessing the least claims upon our confidence as cures for: 
baldness. 



INDEX. 



Abscesses, 151 
Accidents at Birth, 131 
Air, 57 
Alkalies, 94 
Aloes, 130 
Alopecia, 365 
Angina, 174, 255, 261 
Antacids, 94 
Antiphlogistics, 103 
Anthelmintics, 130, 241 
Ani Prolapsus, 212 
Antimony Tartarized, 112 
Anas, Imperforate, 136 
Aphthae, 170 
Arachnitis, 286 
Artificial Feeding, 40 
Ascarides, 239 
Asphyxia, 132 
Asthma Thymicum, 265 
Atelectasis Pulmonum, 135 
Atrophia Ablactatorum, 194 
Bark, 98 
Baths, 119 

Ioduretted, 346 
Bed, 51 

Biscuits, Purgative, 128 
Blisters, 107 
Bloodletting, 103 
Blue Disease, 147 
Boiling Water, Swallowing of, 262 
Bottle, Sucking, 42 
Bow's Opiate Liniment, 93 
Bowels, Healthy state of, 55 

Training of, 47 

Affections of, 190 
Brain, 20, 25 

Irritation of, 274 

Effusion in, 276 

Congestion of, 275 

Inflammations of, 280 
Bread, Ferruginous, 346 
Breasts, Swelling of, 158 
Bronchitis, 251 
Broncho-pneumonia, 252 

cephalite, 270 
Bronchotomy, 262, 264 , 

Bryce's Test, 321 
Burnt Holes, 356 
Calomel, 89 
Cancrum Oris, 181 



Carminatives, 95 

Daiby's, 96 
Castor Oil, 122 
Catarrh, 250 

Bronchial, 251 
Causes of Disease, 66 
Cerebro-spinal System, 20 

Diseases of, 274 
Chalybeate Powder, 99 
Change of Air, 85 
Childhood, 13 

Children, Management of, 31 
Food of, 42 
Still-born, 132 
Chicken-pox, 315 
Choice of Nurse, 39 
Cholera Infantum, 198 
Circulatory System, 18 
Cleanliness, 45 
Climate, 85 
Clothing, 47 
Clyster, 131 
Club Feet, 140 
Cold, 48 
Colic, 212 
Colitis, 221 
Colostrum, 35 
Constitutional Diseases, 338 
Convulsions, 277 
Coryza, 250 
Costiveness, 55 
Cow-pox, 316 
Cowhage, 241 
Coxe's Hive-syrup, 116 
Cradles, 50 
Croup, 255 

Membrane of, 257 

Spasmodic, 258 

Cerebral, 265 
Crowing Inspiration, 266 
Crusta Lactea, 361 
Cupping, 106 
Cutaneous Diseases, 359 
Cyanosis, 147 
Cynanche Parotidea, 189 
Trachealis, 255 
Maligna, 300 
Daiby's Carminative, 96 
Dancing, 53 
Deformities, 135 



370 



INDEX. 



Dentition, 158 

Treatment of, 164 
Diagnosis, 76 
Diaphoretics, 116 
Diarrhoea, 207 
Digestive Organs, 15 

Diseases of, 167 

Functional, 192 
Inflammatory, 218 

Disease, 66 

Signs of, 77 

at Birth, 131 

Constitutional, 338 
Diphtherite, 174 
Dolichos, 241 
Doses of Medicines, 83 
Dressing of Infants, 33 
Dysentery, 221 

Ear, Scrofulous Disease of, 341 
Early Rising, 51 
Eczema, 361 
Education, Physical, 31 
Mental, 58 
Moral, 62 
Religious, 65 
Emetics, 110 
Enema, 131 
Enteritis, 219 
Eruptive Fevers, 292 
Erysipelas, 149 
Erythema, 359 
Etiology, Q6 
Exanthema, 292 
Excitants, 98 
Exercise, 52 
Expectorants, 115 
Favus, 365 

Feeding, Artificial, 40 
Feet, Swelling of, 163 

Deformed, 140 
Fever, 242, 292 
Fingers, Supernumerary,. 141 
Fits, 147, 265, 277 
Foreign Bodies in Larynx, 263 
Food, 35, 36, 42 

of Nurses, 39 
Fractures, 146 
Frenum Linguae, 139 
Funis, 33, 47 

Gangrene of the mouth, 182 
Gardens, Public, 54 
Gastritis, 219 
Gastro-malacia, 201 
Glottis, Ulceration of, 263 

Spasm of, 265 
Gripes, Watery, 211 
Growth, 23 

Gums, Lancing of, 165 
Gum, Yellow, 153 
Red, 157 



Gymnastics, 53 

Hands, Swelling of, 163 

Hare-Lip, 139 

Hardening of Cellular Tissue, 151 

System, 48 
Health, 76 
Heat, 57 

Heat of Infants, 32 
Herniae, 143 
Herpes, 362 
Hide-bound, 151 
Hippo, 111 
Hooping-Cough, 268 
Hoisting, 52 
Huile Purgative, 129 
Hydrargyrum, 88 
Hydrencephaloid Disease, 277 
Hydrocephalus, 282 

Chronic, 285 
Congenital, 286 
Hydrocele, 145 
Hypospadias, 137 
Icterus, 153 
Ileitis, 220 
Impetigo, 361, 365 
Induration, 151 
Infant, 13 

External Characteristics of, 14 

Digestive Organs of, 15 

Respiratary Organs, 17 

Circulatory Organs, 18 

Cerebro-spinal System of, 20 

Senses of, 21 

Locomotive Organs of, 22 

Growth of, 23 

Management of, 31 

Heat of, 31 

Washing of, 32 

Dressing of, 33 

Feeding of, 35, 36, 42 

W T eaning of, 42 

Schools, 65 

Indigestion of, 192 

Cholera of, 198 

Infantile Erysipelas, 149 
Therapeutics, 83. 
Colic, 212 

Infusion of Rhubarb, 127 

Inflation of Lungs, 133 

Inguinal Hernia, 145 

Injuries during Birth, 146 

Intellect, Development of, 27 

Intertrigo, 359 

Inoculation, 314, 323 

Inward Fits, 265, 278 

Iodine, 99, 101 

Ipecacuan, 111 

Iron, 99 

Itch, 360 



INDEX. 



Jacob, Dr Letter from, on Purulent 

Ophthalmia, 155 
Jalap, 128 
Jaundice, 153 
Larynx, Foreign Bodies in, 263 

Inflammation of, 261 
Laryngismus, 265 
Leeches, 105 
Lientery, 211 
Light, 56 

Locomotive Organs, 22 
Lockjaw, 147 
Lumbricoides, 239 
Lungs, Inflation of, 134 
Management of Children, 31 
Magnesia, 124 
Manna, 123 
Maternal Nursing, 36 
Maw Worm, 240 
Measles, 292 
Meconium, 35 
Medicine, 35, 54 
Mercury, 88 
Mesenteric Disease, 228 
Mental Education, 58 
Milk, Substitutes for, 40 
Millet, 173 

Mixture, Anti-emetic, 96 
Carminative, 96 
Exciting, 98 
Terebinthinate, 98 
Strengthening, 99 
Emetic, 112 
Expectorant, 113 
Antimoniated, 114 
Sedative Ipecacuan, 114 
Sedative Squill, 115 
Polygala,U5, 116 
Aloetic, 130 
Astringent, 196 
Senna, 128 
Manna, 123 
Moles, 141 
Moral Education, 62 
Mortality of Infancy, 131 
Mouth, Inflammation of, 169 
Ulceration of, 169 
Gangrene of, 179, 182 
Muguet, 173, 191 
Mumps, 189 
Music, 54 

Navel-string, 33, 47 
Naevi, 141 
Nettle-rash, 360 
Nine-day Fits, 147 
Nursing, Maternal, 36 

Obstacles to, 36 
Rules for, 37 
Nurses, Management of, 38 
Choice of, 39 



371 



Nursery, 51,57 

Medicines, 56 
Obstacles to Nursing, 36 
Ointment, Sedative, 109 
Omphalocele, 143 
Opium, 92 
Opiate Liniment, 93 
Ophthalmia, 153 
Ophthalmia, Scrofulous, 340 
Paralysis, 147 
Pastilles de Manne, 123 
Peculiarities of Infants, 13, 66 
Penis, Imperforate, 136 
Perforation of Bowels, 227 
Peripneumonia, 252 
Pericarditis, 255 
Pemphigus, 356 
Pertussis, 268 
Pes Equinus, 140 
Pleuritis, 255 
Pneumonia, 254 
Polygala, 115 
Porrigo, 361, 365 
Potion Calmante, 117 
Powder, Chalybeate, 99 
Expectorant, 113 
Rhubarb and Magnesia, 126 
Compound Rhubarb, 127 
Jalap and Ipecacuan, 128 
Sedative Ipecacuan, 114 
Scammony and Chalk, 129 
Scammony and Rhubarb, 129 
Prescribing, 83 
Prognosis, 81 
Prolapsus Ani, 212 
Public Gardens, 54 
Pulse 19 
Purging, 54 
Purgatives, 122 

Biscuits, 128 
Purpura, 354 
Pustule, Malignant, 181 
Red Gum, 157 
Refrigerants, 117 
Remittent Fever, 242 
Respiratory Organs, 17 

Diseases of, 250 
Retention of Urine, 137 
Rhubarb, 126 
Rickets, 348 
Ringworm, 362, 365 
Rocking, 50 
Roseola, 297 
Rules for Nursing, 37 

Prescribing, 83 
Rubeola, 292 

Sine Catarrho, 297 
Nigra, 297 
Ruptures, 143 
Salivation, 88 



372 



INDEX. 



Salt, Use of, 350 
Salts, Neutral, 124 
Schools, Infant, 65 
Scabies, 360 
Scalding, 359 
Scald Head, 365 
Scarlatina, 298 

Anginosa, 299 

Maligna, 300 

Faucium, 301 

Treatment of, 303 
Scammony, 129 
Scrofula, 338 
Scrofularia Nodosa, 357 
Scrofulous Glands, 340 

Ophthalmia, 340 

Ulcers, 340 

Ear, 341 

Discharge from Vagina, 341 
Senses, 21 
Sedatives, 91 
Senna, 127 
Sinapisms, 110 
Skin, Diseases of, 359 
Skin-bound, 151 
Sleep, 49 
Small-pox, 308 

Confluent, 309 

Modified, 310 
Snuffles, 250, 352 
Solutio Iodinii, 102 
Somnolency, 275 
Spasm of Glottis, 265 
Spina Bifida, 137 
Spoon-feeding, 40 
Squill, 115,116 
Steel, 98 

Still-born Children, 132 
Stimulants, 97 
Strengthening Mixtures, 98 
Stomach, Affections of, 190 
Softening of, 199 
Stomatitis, 169 
Strophulus, 157 
Strumous Dyspepsia, 339 
Sucking Bottle, 42 
Suppositorium Anthelminticum, 130 
Suppression of Urine, 137 
Sudden Death, 267 
Swelling of Breasts, 158 

Hands and Feet, 163 
Swine-pox, 315 



Syphilis, 350 

Syrup, Simple Sedative, 92 

Compound Sedative, 93 
Tabes Mesenterica, 228 
Tape-worm, 240 
Tartar Emetic, 112, 114 
Teething, 158 
Teeth, Permanent, 166 
Temperament, 30 
Therapeutics, 83 
Throat, Scarlatina of, 301 
Thrush, 169, 174 
Thread-worm, 239 
Thymic Asthma, 265 
Thymus Gland, Enlargement of, 268 
Tinea Capitis, 363 
Toes, Supernumerary, 141 
Tonics, 98 
Tongue-tied, 139 
Tricocephalus, 239 
Trismus, 148 
Tubercle, 344 
Tuberculous Fever, 339 
Tumours on Head, 146 
Turpentine, 98 
Umbilical Cord, 33 

Hernia, 143 
Unguentum Sedativum, 109 

Anthelminticum, 130 
Urine, Retention of, 137 

Suppression of, 137 
Urticaria, 360 
Vaccination, 316 

Spurious, 325 
Vaccine Controversy, 327 
Vagina, Imperforate, 136 

Discharge from, 341 
Valgus, 140 
Varus, 140 
Varicella, 315 
Variola, 308 
Ventilation, 51, 57 
Vernix Caseosa, 14, 32 
Wakefulness, 274 
Washing, 32, 46 
Water, 117 
Water, Boiling, Swallowing of, 262 
Watery Gripes, 211 
Weaning, 42 

Brash, 194 
Worms, 236 
Yellow Gum, 153 



THE END. 



May, 1843. 



Siatrtratfj Wort® 

ON 

ANATOMY, MEDICINE, SURGERY, 

AND 

THE COLLATERAL SCIENCES. 




PUBLISHED BY 

ED. BARRINGTON & GEO. D. HASWELL ; 

Medical Publishers and Booksellers, 
PHILADELPHIA. 



irnw WOIEKS 



PILCHER OIV THE EAR. 

A TREATISE on the STRUCTURE, ECONOMY, and DISEASES of 

the EAR ; being the Essay for which the Fothergillian Gold Medal was 
awarded by the Medical Society of London. By Geo. PiLCHER,late Lec- 
turer on Anatomy, and Lecturer on Surgery at the Theatre of Anatomy 
and Medicine, Webb St., Borough, and Senior Surgeon to the Surrey 
Dispensatory. First American, from the 2d London edition, with Notes 
and numerous illustrative Plates. 

"This is a most valuable treatise, illustrated with elegant plates, is a standard work, and 
must have a great sale in its present form. It teils all about the anatomy and diseases of 
the ear."— N. Y. Herald. 



STANDARD MEDICAL WORKS 



PUERPERAL FEVER. 

THE HISTORY, PATHOLOGY, AND TREATMENT OF PUER- 
PERAL FEVER AND CRURAL PHLEBITIS. By Drs. 
Gordon, Hey, Armstrong, and Lee; with an INTRODUCTORY 
ESSAY by Charles D. Meigs, M.D., Professor of Obstetrics and 
the Diseases of Women and Children in the Jefferson Medical 
College, Philadelphia. 1 vol. 8vo. 

"We have peculiar satisfaction, in announcing the publication of this very judiciously 
arranged seri s of treatises, on one of the most important and interesting diseases, which 
demand the attention of the physician." "Dr. Meigs' Introductory Essay is concise and udi- 
cious, and will be read with profit. He speaks in the highest terms of commendation oif Dr. 
Gordon's invaluabb treatise — a treatise which cannot be too generally diffused and studied. 
Altogether this volume presents the most acceptable and useful compend of the doctrines 
and practice of the best authorities, with regard to 'Puerperal Fever,' with which we have 
ever met."— N. Y. Lancet. 

" We are pleased to see the republication of these valuable monographs upon Puerperal 
Fever. As they are all of them Essays founded upon an extensive observation, and contain 
a very large number of recorded cases, they must always be valuable."— New England 
Jour. Med. Scien. 

" Taken in connexion, the treatises it comprises present an invaluable mass of facts in 
relation to Child-bed Fever, without an acquaintance with which no one can, with propriety, 
be considered fully qualified to undertake its management."— Jour. Med. Stien. 



DIGESTION, 

DERANGEMENTS, PRIMARY and REFLEX, of the ORGANS of 
DIGESTION. By Robert Dick, M.D., author of '« A Treatise on 
Diet and Regimen." 1 vol. 8vo. 

"Tt is the fullest, most comprehensive, and decidedly the best account of derangem* nts of 
the digestive organs that we have encountered. While it embraces all that is important or 
interesting to be found in the writings of other authors, it contains much original informa- 
tion, which the physician will find of great practical usefulness.' — Western and Southern 
Medical Recorder. 

" We recommend this volume most warmly to the attention of our readers. —London 
Lancet, No. 937. 

M This volume may, in fact, be denominated with no small degree of propriety, an ency- 
clopedia of dyspeptic disorders, and we unhesitatingly commend it, as the most useful and 
comprehensive treatise on this class of diseases w ith which we are acquainted." — N. Y.Lancet. 

" We have perused this work with pleasure and instruction. It is decidedly the best 
compilation in the English language on the extensive class of disorders and diseases 
comprehended under the" term dyspepsia, united with a very large proportion of original 
matter, both in the form of able comments on other writers, and practical information 
derived from the author's own experience. — Johnson's Medico- Chirurg. for Jan. 1842. 



SEXVIEIOLOGY. 

OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated 
from the German of Professor Schill. With copious notes by 
D. Spillman, M.D., A.M., &c, &c. 1 vol. 8vo. 

"An elegant and accurate translation of a very ingenious and instructive work. We do 
not know^any other source from which we can so easily and profitably obtain all that is 
really useful in the semeioloey of the ancients: and the erudite translator and editor has 
so very creditably supplied the deficiencies of the author's abrige of the labors of m< dern 
workers, in this most important department of modern science-that we can in good con- 
science commend the book as one of unequivocal merit.— New York Lancet. 



MEDICAL EXPERIENCE. 
CURIOSITIES OF MEDICAL EXPERIENCE. By J. G. Mil- 
lingen, Surgeon to the Forces, Member of the Medical Society of 
the Ancient Faculty of Paris, etc., etc. 

" Curiosities of Medical Experience. By J. G. Milltnges. Surgeon to the Forces, etc. 
The Author or Compiler derived the idea which prompted him to write this work from 
DTsraeli's' Curiosities of Literature;' and, in our view . he has made a book equally 
curious in its way with that one. The heads of his chapters are numerous and varied, 
and all his subjects are treated in an agreeable and comprehensible stvle to the general 
reader. The drift of the Author, too, is decidedly useful. We shall endeavour to give 
some extracts from this work."— J\Tat. Gaz. 



PUBLISHED BY BARRINGTON AND HASWELL. 



MATERIA RZEDXCA. 

A PRACTICAL DICTIONARY OF MATERIA MEDICA, includ- 
ing the Composition, Preparation and Uses of Medicines ; and a large 
number of Extemporaneous Formulae: together with important Toxi- 
cological Observations,- on the Basis of Brande' s Dictionary of Materia 
Medica and Practical Pharmacy ,- by John Bell, M.D., Lecturer on 
Materia Medica and Therapeutics, &e. &c. 1 vol. 8vo. 

"Mr. Brande's is an excellent work, and with the retrenchments, additions, and altera- 
tions of Dr. Bell, may be regarded as one of the most valuable works on the Mater '"a 
Medica we now possess. It has an important advantage over many of the treatises on t his 
subject, in giving a large number of prescriptions for the administration of the principal 
articles. This renders' it especially valuable to tho young practitioner." —Bait. Jour. 

A THERAPEUTIC ARRANGEMENT and SYLLABUS of MATERIA 
MEDICA. By James Johnstone, M.D., Fellow of the College of Physi- 
cians, and Physician to the General Hospital, Birmingham. 
" This book cannot but be particularly useful to those who intend to lecture or write 
upon the- Materia Medica; as well as to the studeuts for whose particular use it is pre- 
pared."— Brit, and For. J\Icd. Rev. 



LIVER AND SPLEEN. 
DISEASES OF THE LIVER AND BILIARY PASSAGES; 
by William Thomson, one of the Physicians of the Royal Infir- 
mary of Edinburgh; and CLINICAL ILLUSTRATIONS OF 
THE LIVER AND SPLEEN, by William Twining; Surgeon 
of General Hospital of Calcutta, &c;, &c. 1 vol. 8vo. 

" The work before us is an excellent compilation of the subject of hepatic affections, 
functional and structural; and, as such, it is infinitely more valuable to practitioners and 
students, than any original essay, however ably executed. We cannot do better, therefore, 
than strongly recommend the work as the best in the English language, on the important 
subjects of which it treats.— Medico-Chirurg. Rev., October, 1841. 

"These two works, when united, form, we may safely say, one of the most valuable and 
attractive volumes on this important class of diseases which have been issued from the 
press. We may, en passant, remark, that the volume is got up in a very superior style."— 
N. Y. Lancet, March 26, 1842. 

CLINICAL REMARKS ON SOME CASES OF LIVER ABSCESS 
PRESENTING EXTERNALLY. By John G. Malcolmson,M.D. 
Surgeon Hon. E. I. C. Service, Fellow of the Royal Asiatic Society, and 
the Geological Society, London, 1 vol. 8vo. 

HUNTERS TREATISE ON THE VENEREAL DISEASE. With Notes 
by Dr. Babington. With Plates. I vol. 8vo. 
"Under the hands of Mr. Babington, who has performed his task as editor m a very 
fxemnlary manner, the work has assumed quite a new value and may now be as 
advantageously placed in the library of the student as in that of the experienced sur- 
geon."— Brit. £ For. Med. Rev. 

A PRACTICAL TREATISE ON VENEREAL DISORDERS, AND 
MORE ESPECIALLY ON THE HISTORY AND TREATMENT 
OF CHANCRE. By Philippe Ricokd, M.D., Surgeon to the Venereal 
Hospital at Paris. 1 vol. 8vo. 

GRAVES 6c GERHARD. 

CLINICAL LECTURES; by Robert J. Graves, M.D, M.R.S.A , 
Professor of the Institutes of Medicine m the School of Physic 
Trinitv College, Dublin, with additional Lectures and Notes, by 
W W Gerhard, M.D., Lect. on Clin. Med. to the Univ. of Penn., 
Physician to the Philadelphia Hospital, Blockley, etc. 1 vol 8vo. 

u in Jh.volnme before us a seriesof clinical lectures by Dr. Gerhard is g.ven, and forms a 
«' In the volume Deiore us, , a .se ^» Graves. Between these two dis- 

most appropriate and ^^tef^"^™^ resemblance. We find in both the same 

vingu.shedphys.c.answecantr^ 

£Sin?S theTame 'd'sre'ard of fdle theory,- and the same decision in the applicat.on 
Jf'rigL prindpks No »or practitioner* should be without tins volume. It lS xn Uself 
alibrury of practical medicine. 1 — N. Y. Lancet. 



STANDARD MEDICAL WORKS 



DISEASES OF CHILDR3W. 
TREATISE ON THE DISEASES OF CHILDREN; WITH 
DIRECTIONS FOR THE MANAGEMENT OF INFANTS; 

by the late Michael Uxderwood, M.D. From the ninth English 
edition, with Notes, by S. Merriman, M.D., and Marshall Hall, 
M.D., F.R.S., etc. ; with Notes, by John Bell, M.D.. etc., of 
Philadelphia. 1 vol. 8vo. 



JETXOXiOaV. 

ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE and 
CHRONIC DISEASE. From the Greek, by T. F. Reynolds, 
M.B., F.L.S., &c, &c. 1 vol. 8vo. 

" The correct detail of symptoms, ihe nervous style, the graphic delineation of disease, 
displayed in this author's work, the poetic and quaint fancies scattered throughout, give a 
certain value and interest, that may fairly excuse an attempt to reinvest partof them in a 
vernacular garb." 

" We certainly have no hesitation in recommending this curious volume to the notice of 
our readers, lis price is a mere trifle."— New York Lancet. 



EYES. 

A xMANUAL OF THE DISEASES OF THE EYE. By S. Littell, 
Jr., M.D., one of the Surgeons of the Wills' Hospital for the Blind 
and Lame, &c., &c. 

" We confidently recommend the work of Dr. Littell to the senior, as well as to the 
junior, members of the profession. It is replete with information ; yet so terse in stjle, 
and compressed in bulk, as at once to entice and repay perusal. It is no small triumph 
to the author to be able to say that he has introduced almost all that is valuable, and 
everything absolutely necessary to the student within the compass of 200 pages, and we 
would deliberately recommend our young friends to read this work."— Br. % For. Med. Rev. 



GU1VTS. 

THE GUMS ; with late Discoveries on their Structure. Growth, Connections, 
Diseases, and Sympathies. By George Waite, Member of the London 
Royal College of Physicians. 1 vol. 6vo. 



TEETH. 

A TREATISE ON THE TEETH. By John Hunter. With Notes by 
Thomas Bkll, F.R.S. With Plates. 1 vol. Svo. 
•* The treatise on the teeth is edited by Mr. Bell, a gentleman accomplished in his 
art. Mr. Bell has studied his subject with the" greatest minuteness and care: and in ap- 
propriate notes at the foot of the page corrects the author with the air of ■ gentleman, 
and the accuracy of a man of science. The matter contained in these short notes forms 
an ample scholum to the text ; and without aiming at the slightest display of learning, 
they at the same time exhibit a ready knowledge on every point, and an extensive in- 
formation both of comparative anatomy and pathology.— Med. Gtr-tttt. 



CONSTIPATION. 

A TREATISE on the CAUSES and CONSEQUENCES of HABITUAL 
CONSTIPATION. By John Burke, M.D., Fellow of the Royal College 
of Physicians, Physician to the Westminster Hospital, ifcc. 1 vol. Bvo. 
"For some interestine cases illustrative of this work, the author is indebted to Pr. Williams, 

Dr. Stroud. Dr. Callawav, Mr. Morsran. Mr. Taunton, Pr. Roots, Sir Asilev Cooper. Sir 

Benjamin Brodie,Mr. Tupper, Mr. Bailer, Dr. Paris. Mr. Dendy, Dr. Hen. U.Thomson,'' 

kc— Preface. 



PUBLISHED BY BARRINGTON AND HASWELL. 



CHEST. 

LEC iIV^ ES ?," ^.PHYSIOLOGY and DISEASES of the CHEST, 
chieflvhl » ^ nnc ;P' es 0f Ph ^ cal aHd General Diagnosis, illustrated 
ch.efly by a rational Exposition of their Physical Signs: with new re- 
searche son the sounds of the heart. Br Chiles J. b! Williams, M.D. 
Inird edition, 1 vol. 8vo. 

" We d s 1r>n y X rUten by a "jan thoroughly acquainted with his sul ]ea."-Lancet. 
" Wad. HlJ ZyJJ" Work t0 the a V lention of aus C ultators.»-MM. Chir. Rev. 
workf-'-li ftL? J 7W? / h / S °Pll or r tun| ty of strongly recommending this very valuable 
"'Of 11 "£■ * orbes s -translation of Laennec. 

Med.Gaz. * 0IUh ' S sub J ect > We are inclined much t0 P ref er that of Dr. Williams."- 

LEC 3iS? T 5 1 S 0N THE DIAGNOSIS, PATHOLOGY, AND TREAT- 
MENT OF THE DISEASES OF THE CHEST. By W. W. 
Gerhard, M.D., Lecturer on Clinical Medicine in the University of 
Pennsylvania, etc., etc. 1 vol. 8vo. 
" A series of clinical lectures — concise, lucid, and eminently instructive. We have no 
more able expositor of diseases .if the chest than Dr. Gerhard, and any work of his on these 
Yorklanret' 1 ^ 1313 cerlam of S rateful acceptance by his professional brethren. "-New 
To our readers, therefore, we recommend the book of Dr. Gerhard as the fullest and 
mosr judicious manual, in relation to the diseases of the chest, which they can procure."— 
Western an I Southern Recorder, June, 1842. 

" These lectures constitute a useful and practical digest of the existing knowledge of the 
diseases ol the chest (lungs and heart)."— Bulletin of Medical Science. 

A PRACTICAL TREATISE onlhe PRINCIPAL DISEASES of the 
LUNGS. Considered especially in relation to the particular 
Tissues affected, illustrating the different kinds of Cough. By 
G. HumeWeatherhead, M.D., Member of the Royal College of Physi- 
cians, Lecturer ou the Principles and Practice of Medicine, and on Materia 
Medica and Therapeutics, &c. &c. 1 vol. 8vo. 

PRACTICAL OBSERVATIONS on~DISEASESof the HEART, LUNGS, 
STOMACH, LIVER, &c, OCCASIONED by SPINAL IRRITA- 
TION: AND ON THE NERVOUS SYSTEM IN GENERAL, AS A 
SOURCE OF ORGANIC DISEASE. Illustrated by Cases. By John 
Marshall, M.D. 1 vol. 8vo. 



CUTANEOUS DISEASES. 

A PRACTICAL TREATISE ON DISEASES OF THE SKIN, arranged 
with a view to their Constitutional Causes and Local Character, &c. 
By SAMUEL PLUMBE, late Senior Surgeon to the Royal Metropolitan 
Infirmary for Children, <&c. Illustrated with Splendid Coloured Copper- 
plate and Lithographic Engravings. ] vol. 8vo. 

Plombe on Diseases of the Skin. — " This excellent Treatise upon an order of diseases, 
the pathology pf which is. in general, as obscure as the treatment is empirical, has just 
been republished, edited by Dr. John Bell, of this city. We hail with pleasure the appear- 
ance of any new work calculated to elucidate the intricate and ill-understood subject of 
skin-diseases. The late Dr. Mackintosh, in his Practice of Physic, recommends it as the 
4 best pathological and practical treatise on this class of diseases, which is to be found 
in anv language.'"— P/iil. Med. Exam., Jan. 17, 1838. 

" Tliis work is one of the most excellent on the Diseases of the Skin in the English 
language."— West. Jour, of Med. and Phys. Sciences, Jan. 1838. 



BANDA&ES AND BAWBAGING, 

THE SURGEON'S PRACTICAL GUIDE IN DRESSING, and in the 
Methodic APPLICATION of BANDAGES. Illustrated by one hun- 
dred engravings. By Thomas Cutler, M.D., late Staff Surgeon in the 
Belgian Army. 2d American from the 3d London edition. 

" The Author seems to have spared no pains in procuring correct descriptions of all the 
surgical apparatus, at present employed in bandaging and dressing, both at home and 
abroad. He has given numerous illustrations, in the form of well executed woodcuts, ana 
has altogether produced what we conceive to be a very useful, and by no means an ex pen- 
sive publication."— Medical Gazette. 



STANDARD MEDICAL WORKS 



TETANUS. 

A TREATISE ON TETANUS, being the ESSAY for which the Jackson ian 

Prize was awarded by the Royal College of Surgeons in London. By 

Thomas Blizard CuRLiNG,Assistant Surgeon to the London Hospital,&c. 

" This book should be in the library of every surgeon and physician. It is a valuable 

work of reference. It does not pretend to originality, for originality on such a subject 

was not wanted. But a compendium of facts was wanted, and such a compendium is this 

volume. We cannot part from Mr. Curling without thanking him for the information 

we have received in reading his work, and for the matter it has enabled us to offer 

to our readers." — Medico- Chir. Rev. 



BLOOD, INFLAMMATION, ETC. 

TREATISE ON THE BLOOD, INFLAMMATION, AND GUN-SHOT 
WOUNDS. By John Hunter, F.R.S. With Notes, by James F. Palmer, 
Senior Surgeon to the St. George's and St. James's Dispensary, &c, &c. 
1 vol. 8vo. 

LECTURES ON BLOOD-LETTING. By Henry Clctterbuck, M.D. 

1 vol. 8vo. 

HISTORICAL NOTICES ON THE OCCURRENCE OF INFLAMMA- 
TORY AFFECTIONS OF THE INTERNAL ORGANS AFTER 
EXTERNAL INJURIES AND SURGICAL OPERATIONS. By 
William Thompson, M.D., &c. &c. 1 vol. 8vo. 

A TREATISE ON INFLAMMATION. By James Macartney, F.R.S. , 
F.L.S., &c., «&c. Member of the Royal College of Surgeons, London, 
&c., &c. 1 vol. 8vo. 

LECTURES ON THE BLOOD, and on the CHANGES which it 
undergoes during DISEASE. By F. Magendie, M.D. 1 vol. 8vo. 



ANIMAL (ECONOMY. 

OBSERVATIONS ON CERTAIN PARTS OF THE ANIMAL CECO- 
NOMY, Inclusive of several papers from the Philosophical Transactions, 
&c. By John Hunter, F.R.S., &c, &lc. With Notes by Richard Owen, 
F.R.S. 1 vol. 8vo. 



MIDWIFERY, 
LECTURES ON THE PRINCIPLES AND PRACTICE OF MID- 
WIFERY. By James Blcndell, M.D. Edited by Charles Sevebx, 
M.D. 1 vol. 8vo. Just published. 

" The eminently fluent and agreeable style — the large anil accurate information — the 
great experien e — and originafmind of Dr. Blundell have secured for him a very enviable 
reputation as a public lecturer. It is impossible to read these lectures without being delighted 
— it is equally impossible to avoid being instructed. Weie these discourses more"gent r rall>' 
diffused and studied here — were their~sound and judicious directions recollected and their 
salutary cautions observed, we would hear of fewer cases of malpractice. This work forms 
a complete system of midwifery, with the diseases of ths puerperal slate and o! the infant.''— 
JV. Y. Lancet. 

A PRACTICAL TREATISE on MIDWIFERY; Containing the Results 
of Sixteen Thousand Six Hundred and Fifty-four Births, occurring in 
the Dublin Lying-in Hospital. By Robert Collins, M.D., Late Master 
of the Institution. 1 vol. 8vo. 
"The author of this work has employed the numerical method of M. Louis : and by 
accurate tables of classification, enables'his readers to perceive, at a glance, the conse- 
quences of the diversified conditions, in which he saw his patients. Avast amount of 
information is thus obtained, which is invaluable to those who duly appreciate precision 
in the examination of c*ses."— J5a/£. Chron. 

A PRACTICAL COMPENDIUM OF MIDWIFERY; being the 
Course of Lectures on Midwifery and on the Diseases of Women 
and Infants delivered at the St. Bartholomew's Hospital by the 
late Robert Gooch, M.D. Prepared for Publication by George 
Skinner, Member of the R. Coll. of Surg., Lond. 1 vol. bvo. 



PUBLISHED BY BARRINGTON AND HASWELL. 



ARMSTRONG'S LECTURES. 

LECTURES on the MORBID ANATOMY, NATURE, and TREAT- 
MENT of ACUTE and CHRONIC DISEASES. By the late John 
Armstrong, M.D.; Author of '• Practical Illustrations of Typhous and 
Scarlet Fever," &c. Edited by Joseph Rix, Member of the Royal Col- 
lege of Surgeons. J vol. 8vo. 
The British and Foreign Medical Review savs of this work : 
'•We admire, in almost every page, the precise and cautious practical directions; the 
striking allusions to instructive cases; the urgent recommendations of the pupil to 
be careful, to be diligent m observation, to avoid hurry and heedlessness, to be atten- 
tive to the poor. Nothing can be -more excellent than the rules laid down for all the 
parts of the delicate management of fever patients: nothing more judicious than the 

general instructions arising out of the lecturer's perfect knowledge of mankind 

His prudent admonitions respecting the employment of some of the heroic remedies, as 
mercury, arsenic, and colchicum, attest his powers of observation and his practical 
merits." " The pious office of preserving and publishing his Lectures has been performed 
by Mr. Rix, with singular ability." 



isrsANiTir. 

A TREATISE on INSANITY and other DISEASES AFFECTING the 
MIN D. By James Cowles Prichard, F. R.S. M-D. Corresponding Member 
of the Institute of France, &c. 1 vol 8vo. 
" The author is entitled to great respect for his opinions, not only because he is well 
known as a man of extensive erudition, but also on account of his practical acquaint- 
ance with the subject on which he writes. The work, we may safely say, is the best, 
as well as the latest, on mental derangement, in the English language."— Medico-Chir, 
Jico. 

A TREATISE ON MENTAL DISEASES, By M. Esquirol. 

APHORISMS on the TREATMENT and MANAGEMENT of tho 
INSANE: with considerations on Public and Private Lunatic 
Asylums, pointing out the errors in the present system. By J. G. 
Millingen, M.D., late Medical Superintendent of Lunatic Asylum, 
Hanwell, Middlesex, &c. 1 vol. 8vo. 

"Dr. IMillingen, in one small pocket volume, has compressed more real solid matter 
than could be gleaned out of any dozen of octavos on the same subject. We recommend 
his vade mecum as the best thing of the kind we ever perused."— Dr. Johnson'' s Review. 



PHYSICAL AGENTS. 

ON THE INFLUENCE of PHYSICAL AGENTS on LIFE. By W. F. 
Edwards, M.D., F.R.S., etc. Translated from the French, by Drs. 
Hodgkin and Fisher. To which are added, some Observations on Elec- 
tricity, and Notes to the work. 1 vol. 8vo. 
" This is a work of standard authority in Medicine ; and, in a physiological point of 
view, is pre-eminently the most valuable publication of the present century ; the experi- 
mental investigation instituted by the author, having done much towards solving many 
problems hitherto but partially understood. The work was originally presented in parts 
to the Royal Academy of Science of Paris, and so highly did they estimate the labours 
of the author and so fully appreciate the services by him thus rendered to science and 
to humanity, that they awarded him, though a foreigner, the prize founded for the 
promotion of experimental physiology. 

cXiixracAXi xvxsDxcixra. 

MEDICAL CLINIC; or, Reports of Medical CASES: By G. 
Andral, Professor of the Faculty of Medicine of Paris, etc. 
Condensed and Translated, with Observations extracted from the 
Writino-s of the most distinguished Medical Authors : By D. Spil- 
lan M.D., etc., etc. ; containing Diseases of the Encephalon, &c. 
with Extracts from Ollivier's Work on Diseases of the Spinal Cord 
and its Membranes. 1 vol. 8vo. 

LECTURES on Subjects connected with CLINICAL MEDTCINE. By 
P. M. Latham, M.D. Fellow of the Royal College of Physicians and 
Physician to St. Bartholomew's Hospital. 
-We stronglv recommend them [Latham's Lectures] to our readers; particularly 

to pupils attending the practice of our hospitals.' -Land. Med. Gaz. 



STANDARD MEDICAL WORKS 



SURGERY. 

ELEMENTS OF SURGERY, in Three Parts. By Robert Listen, Fel- 
low of the Royal College of Surgeons in Loudon and Edinburgh, Surgeon 
to the Royal Infirmary, Senior Surgeon to the Royal Dispensary for 
the City and County of Edinburgh, Professor of Surgery in the London 
University, &c. &c. Third American, from the Second London Edition, 
with upwards of one hundred and sixty illustrative engravings. Edited by 

SAMUEL D. GROSS, M.D., 
Professor of Surgery, Louisville Medical Institute. Author of Ele- 
ments of Pathological Anatomy, etc., etc. 1 vol. 8vo. 

" We must not forget to mention that the volume is rendered still more attractive by the 
addition of numerous wood engravings (some of them introduced bv Dr. Gross), all finely 
executed. These will be found of very considerable advantage to the student, materially 
assisting him in comprehending the explanation of morbid structure. Another admirable 
feature, is the printing of the notes in type of the same size as that of the text. This obvi- 
atesalmost entirely, whatever objections can be alleged asainst fout-notes. r — Western Jour, 
of Med. and Surg., Dec, 1S42. 

,; We are here presenied with a republication of Mr. Liston's admirable and much praised 
work on Surgery, which has been subject to the alembic of a critical and learned friend, 
Dr. Gross. He has added ' copious notes and additions,' such as the progress of surgery 
in the United States demands in order to meet the wants of the surgeon. iProfessor Gross 
has also given an entire article on Strabismus, and another on Club Feet, which were wholly 
omitted in the English copies. They miy be regarded important, inasmuch as they give a 
completeness to an otherwise unfinished treatise". The execution of the book is good; the 
paper firm, and well secured in the binding. The plates are uniformly well executed, and 
the impressions distinct."— Boston Med. and Surg. Jour. 

"In another essential feature this edition is greatly improved. With the principles is 
taught also with it the practice of surgery; and both morbid structure and operations are 
doubly described ; first by the author and editor, and next by the graver of the artist."— 
Bull. Med. Scien. 

" Mr. Listonhas seen much, thinks accurately, and speaks independently. From a volume 
written by such a man, more really valuable practical instruction is to be derived than from 
all the books that were ever compiled."— Western and Southern Med. Recorder. 

"This is a work of established reputation. It has gone through two editions in Great 
Britain, and the same number in this country. The aJditiuns of the American edition are 
copious, and add materially to the value of the work." — Atner. Jour. Med. Sciewes. 

"The author is bold and original in his conceptions, accurate in deductions, plain 
and concise in style; a combination of good qualities not often found united in a single 
volume. The notes and additions, by Prof, Gross, are well arranged and judicious, sup- 
plying some evident deficiencies in the original work."— Western Lancet. 

LECTURES OF SIR ASTLEY COOPER on the PRINCIPLES 
and PRACTICE of SURGERY, with additional Notes and 
Cases. By Frederick Tyrrell, Esq., Surgeon to St. Thomas's 
Hospital, and to the London Ophthalmic Infirmary. 1 vol. 8vo. 

LECTURES ON THE PRINCIPLES OF SURGERY. Br John 

Hunter, F.R.S. With Notes by James F. Palmer, Senior Surgeon to 

the St. George's and St. James' Dispensaries, &c. &c. With Plates. 

1 vol. 8vo. 

" We cannot bring our notice of the present volume to a close without offering our 

testimony to the admirable manner in which the editor and annotator has fulfilled his 

part of the undertaking. The advancements and improvements that have been effected, 

up to our own day, not only in practical surgery, but in all the collateral departments, 

are constantly brought before the reader's attention in clear and concise terms."— 

Brit. $ For. Med. Rev. 

JOHN HUNTER'S WORKS. 
THE COMPLETE WORKS OF JOHN HUNTER, F.R.S., 4 vols. 
8vo., comprising his Lectures on the Principles of Surgery; A 
Treatise on the Teeth; Treatise on the Venereal Diseases; Trea- 
tise on Inflammation and Gun-Shot Wounds ; Observations on 
Certain Parts of the Animal (Economy ; and a full and comprehen- 
sive Memoir. Each of the Works is edited by men of celebrity in 
the Medical Science, and the whole under the superintendence of 
Jas. F. Palmer, of the St. George's and St. James's Dispensary. 
This is the only complete edition of the works of the distinguished 
physiologist ever published in this country. 

"One distinctive feature of the present edition of Hunter's works has been already 
mentioned, viz: .in the addition of illustrative notes, which are not thrown in at hazard, 
but are written by men who are already eminent tor their skill and attainments on the 
particular subjects which they have thus illustrated. By this means, whilst we have the 



PUBLISHED BY BARRINGTON AND HASWELL. 



views entire of John Hunter in the text, we are enabled by reference to the accompanying 
notes, to see wherein the author is borne out by the positive knowledge of the present "day, 
or to what extent his views require modification and correction. The names of the 
gentlemen who have in this manner assisted Mr. Palmer, are guarantees of the successful 
performance of tueir task."— Med. Gaz. 



HYSTERIA. 

AN ESSAY ON HYSTERIA, being an analysis of its irregular and aggra- 
vated forms; including Hysterical Hemorrhage and Hysterical Ischuria. 
With numerous Illustrative and Curious Cases. By Thomas Laycock, 
House Surgeon to the York County Hospital. 1 vol.8vo. 



UTERUS. 

LECTURES on the FUNCTIONS and DISEASES of the WOMB, 

by Charles Waller, M.D., Bartholomew's Hospital. 

ON DISEASES of the UTERUS and its APPENDAGES, by M. 

Lisfranc, La Pitie Hospital. 

ON DISEASES of the PUERPERAL STATE, by J. T. Ingleby, 
Edinburgh. 1 vol. 8vo. 

* We can very cordially recommend them as affording a concise and practical exposition 
of the pathology ami treatment of a most important class of diseases, and which cannot be 
too attentively ■United."— If. Y. Lancet. 

'• The present volume contains a short and succinct practical account of the principal mor- 
bid slates either of ilie functions or the structure of the womb, the best methods of dis- 
tinguishing them, and the means which experience has shown to be the most effectual in 
removing iheni. The reader will find that he obtains, in a small compass, a distinct view 
of the nature and treatment of each disorder."— Edinb. Med. and Surg. Journ. 



URINARY DISEASES. 

URINARY DISEASES and their TREATMENT. By Robert Wil- 
lis, M.D., Physician to the Royal Infirmary for Children, &c. &c. 
"We do not know that a more competent author than Dr. Willis could have been 
found to undertake the task ; possessing, as it is evident from his work that he does 
ss, an accurate acquaintance with the subject in all its details, considerable per- 
sonal experience in the diseases of which he treats, capacity for lucid arrangement, and 
a style of communication commendable in every respect."— Brit. &} For. Med. Rev. 

AMUSSAT'S LECTURES on the RETENTION of URINE, CAUSED by 
STRICTURES of the URETHRA, and on the Diseases of the Prostate, 
translated from the French by James P. Jervey, M.D. 



EPIDEMICS OF THE MIDDLE AGES. 

FPIDEMICS of the MIDDLE AGES. From the German of I. F. C. 
Hecker, M.D., &c. &c. Translated by R. G, Babington, M.D. F.R.S.- 

No . i.-TIIE BLACK DEATH IN THE 14th CENTURY. 

■ Hecker^ account of the ' Black Death,' which ravaged so large a portion of the globe 

in th fimrlSth century, mav be mentioned as a work worthy of our notice both as 

. -^ mV,,vinti.re«t"i ^details of this tremendous pestilence, and as exhibiting a 

t^^^T^^^^^cU^eMa of Practical Medicine-History of 

Medicine by Dr. Bostock. T ^ T ^ T ^ », , XTT * 

No. II — THE DANCING MANIA. 

., %* a- ,1 u;-tnrv Ins lon» been in need of the chapter which this book supplies; and 
•Medical Hlstor > ha „ s t ^"° v ° l P n remedied at a better season. On the whole, the 
the deficiency could no ^ e ^ "nufljett acceptable, as con- 

volume ought obepopu lar, »° in J £ ° 1C ; imDortant subject which had almost been 
veying so much "^/" iat '° n .^ especial thanks 

Buffered to be buried in , obhi on a dw e l ^ nk ™ ion _ The st * le f the translation. 
^^£^Tl^t^£o^\t ?eads like an English original,'-^.. 
Med. Gaz. 



10 



STANDARD MEDICAL WORKS 



PHYSIOLOGY AND HYGIENE. 
ESSAYS ON PHYSIOLOGY AND HYGIENE; viz: 

I. Reid's Experimental Investigation into the Functions of the Eighth 

Pair of Nerves. 

II. Ehrenberg's Microscopical Observations on the Brain and Nerves 

(with numerous engravings). 

III. On the Combination of Motor and Sensitive Nervous Activity; 

by Professor Stromeyer, Hanover. 

IV. Vegetable Physiology. 

V. Experiments on the Brain, Spinal Marrow, and Nerves. By 
Prof. Mayer, of Bonn (with woodcuts). 

VI. Public Hygiene. 

VII. Progress of the Anatomy and Physiology of the Nervous Sys- 

tem, during 1836. By Professor Muller. 

VIII. Vital Statistics. 1 vol. 8vo. 



ANATOMICAL EXAMINATIONS. 

EXAMINATIONS in ANATOMY and PHYSIOLOGY; being a 

complete series of Questions and Answers; designed and intended 
as preparatory to Examinations at the different Medical Schools 
throughout the United States. To which are annexed, Tables of 
the Bones, Muscles, and Arteries. By Thomas Sydenham Bryant, 
M.D., Surgeon U. S. Army. 

"This is a very useful manual of anatomy. We have pleasure in recommendins it to the 
favourable notice of students. They will find it of immense service in preparing for exami- 
nations." — N. Y. Lancet. 

THE LONDON DISSECTOR, OR GUIDE TO ANATOMY; 

for the use of students : comprising a description of the muscles, 
vessels, nerves, lymphatics, and viscera of the human body, as they 
appear on dissection ; with directions for their demonstration. 
Revised and corrected by Edward J. Chaisty, M.D., &c, &c. 
1 vol. 12mo. 

8 Although there are several of these dissectins-room companions, there is not one in the 
whole catalogue that wears better, from its intrinsic value, than the eld London Dissector. 
With the improvements of litis excellent edition, carefully revised, it will prove a very 
economical as well as certain assistant ; and it therefore commends itself to the student.''— 
Boston Med. and Surg. Jour. 



JUST PUBLISHED, 

EVANSON 6L ItIAUKTSSLL. 
PRACTICAL TREATISE ON THE MANAGEMENT AND DIS- 
EASES OF CHILDREN. By Richard T. Eyanso.v, M.D., Professor 
of Medicine, —and Henrv Mailvsell, M.D., Professor of Midwifery 
in the Col. of Sur^s. in Ireland. From the 4th Dublin edition. Edited 
by D. F. Condie, M.D. 



ANDRAL, OX THE ABDOMEN. 

MEDICAL CLINIC: DISEASES OF THE ABDOMEN. By G. A>dkal. 
M.D., Professor to the Faculty of Paris, Member of the Royal Academy of 
Mediciue, etc., etc. Condensed and Translated, with Observations, by 
D. Spillan, M.D., Fellow of the King and Qneeu's College of Physicians 
in Ireland, Member of the Association of the Fellows and Licentiates of the 
College of Physiciaus, aud Formerly Physician to the Dublin General 
Dispensary. 



STOKES AND BELL. 

LECTURES ON THE THEORY AND PRACTICE OF PHY- 
MC By W illiam Stokes, M.D., Lecturer at the Medical School, 
^ark Street, Dublin : Physician to the Meath County Hospital, 
etc., etc., and John Bell, M.D., Lecturer on Materia Medica and 
Therapeutics : Member of the College of Physicians, Philadelphia, 
and of the American Philosophical Society, etc., etc. Second 
American Edition. 2 vols. 8vo. 



valuable J» tv, n £n,, a , M T ed lh , 6 f ° rm °J \ qu ! te complete system of medicine, equally 
InVSif ^ k l ? xl V b0 ' ,!: , 1 ? l * e student, and a book of reference to the practitioner." " We 
; r Jl. k ^°° k ° f , l ^ e k,nd wh '. ch we would more readil y P la " in thu hands of a student, 
?.,?» »r ^ e W0 Jf, ia mor ? readll y refer lhe Practitioner, for a hasty investigation of a sub^ 
jeet. — Aeu> Eng. Quart. Journ. of Med. and Surg. 

»«n .f^tf andl ' 8 F" cl ,'r e U i. ,l,g among the best works extant on Practical medicine, 
will at once commend itself to the practitioners of our country. It is not going too far to 
declare, that no physician, whether his experience be large or small, should be without this 
work in his library; and, having it there, he should study its various parts with care and 
attention."— Western Lancet. 

'•A second edition of this work of established reputation, is sent out from the press of 
Messrs. Barnngton and Haswell, Philadelphia. No change in the mind of the medical public, 
touching the worth of this very celebrated series of medical lectures, has been wrought by 
tne advent of later publications on the same subjects. It is just as popular as ever, and we 
believe, at this moment, is exerting a far more extensive influence than was ever predicted 
by the warmest personal friends of the two learned authors."— Boston Med. and Surg. Jour. 

The following is from the pen of a distinguished Professor in one of the Medical 
Schools in the West. 
" We cordially recommend the joint labours of two such distinguished phvsicians as 
Drs. Stokes and Bell to the notice of the medical profession. They will be found to em- 
body the principles and practice of medical sciencedown to the present moment."— Louis- 
ville Journal. 



MISCELLANEOUS. 



OUTLINES OF GENERAL PATHOLOGY. By George Freckleton, 
M.D., Fellow of the Royal College of Physicians. 

OBSERVATIONS on the PRINCIPAL MEDICAL INSTITUTIONS 
and PRACTICE of FRANCE, ITALY, and GERMANY: with Notices 
of the Universities, and Cases from Hospital Practice: With an Appen- 
dix on ANIMAL MAGNETISM and HOMOEOPATHY. By Edwin 
Lee, Member of the Royal College of Surgeons, &c. 1 vol.8vo. 
" Mr. Lee has judiciously selected some clinical cases, illustrating the practice pursued 

at the different hospitals, and he has wound up the volume with an amusing account of 

annual magnetism and homoeopathy — those precious effusions of German idealty, for 

w Inch we refer to the work itsaM.—Medico-Chirurg. Rev. 

BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM IN GEN- 
ERAL. Translated from the French, by James Kitchen, M.D., Philada. 

MEDICAL AND TOPOGRAPHICAL OBSERVATIONS upon the 
MEDITERRANEAN and upon PORTUGAL, SPAIN,AND OTHER 
COUNTRIES. By G. R. B. Horner, M.D., Surgeon U. S. Navy, 
and Honorary Member of the Philadelphia Medical Society. With En- 
gravings. 1 vol. 8vo. 
" An uncommonly interesting book is presented to those who have any disposition to 

know the tilings medical in Portugal, Spain, and other countries," and" will doubtless 

1m> read, also, with marked satisfaction by all who have a taste for travels.— Bost. Med. 

and Surg. Jour. 

AN ESSAY ON DEW, and several Appearances connected with it, 
by William Charles Wells, M.D.,F.R.S., etc. 

ON DENGUE; ITS HISTORY, PATHOLOGY, AND TREATMENT. 
By S. Henry Dickson, M.D., Professor of the Institutes and Practice 
of Medicine in the Medical College of S.C. 

HINTS ON THE MEDICAL EXAMINATION OF RECRUITS FOR 
THE ARMY; and on the Discharge of Soldiers from the Service on 
Surgeon's Certificate : Adapted to the Service of the United States. By 
Thomas Henderson, M.D., Assistant Surgeon U. S. Army, &c, &c. 



12 



STANDARD MEDICAL WORKS, ETC. 



3mSCEI,X.ANEOUS- Continued. 
MEDICAL NOTES AND REFLECTIONS. By Henry Holland, M.D.; 
F.R.S., Fellow of the Royal College of Physicians, and Physician Extra- 
ordinary to the Queen. 

THE MEDICAL PROPERTIES of the NATURAL ORDER RANUN- 
CULACEiE,&c, &c. By A. Tornbull, M.D. 

Prof. HORNER'S NECROLOGICAL NOTICE OF DR. P. S. 
PHYSICK ; Delivered before the American Philosophical Society, 



May 4, 1838. 

THE LIFE OF JOHN HUNTER, F.R.S. By Drewry Ottley. 
1 small vol. 8vo. 
"In the summing up of Mr. Hunter's character, Mr. Ottley exhibits equal judgment and 
candour."— Brit. # For. Med. Rev. 

ESSAY UPON THE QUESTION, 18 MEDICAL SCIENCE FAVOR- 
ABLE TO SCEPTICISM? By James W. Dale, M.D., of New- 
castle, Delaware. Pamphlet. 

METEOROLOGICAL REGISTER for the years 1826-30 ; from Observa- 
tions made by Surgeons of the Army and others at the Military Posts of 
the United States. Prepared under the direction of Thomas Lawsok, 
M.D., Surgeon-General U.S.A. 

In Press, 

ARAN'S PRACTICAL MANUAL ON DISEASES of the HEART and 
GREAT VESSELS. Translated from the French. 

A TREATISE on BANDAGING and MINOR SURGERY; or, Hints on 
the Every-day Duties of the Surgeon. By H. H. Smith, M.D., Lecturer on 
Minor Surgery, Fellow of the College of Physicians, Member of the Phila- 
delphia Medical Society. Illustratedf by Engravings. 

PRACTICAL MEDlCiNE. Illustrated by Cases on the most Important 
Diseases. Edited by John M. Gait, M.D. 

B. fy H. continue to publish 

THE SELECT MEDICAL LIBRARY 

AND BULLETIN OF MEDICAL SCIENCE. 

EDITED BY JOHN BELL, M.D., 
AT FIVE DOLLARS PER ANNUM, IX ADVANCE. 

Each No. of the Library will consist of one or more approved works 
on some branch of Medicine, including, of course, Surgery and Obstetrics. 

Every work in the Library will be completed in the number in 
which it is begun, unless the subject naturally admits of division; and 
hence the size of the numbers will vary. It will be done up in a strong 
paper cover, and each work labelled on the back; thus obviating the 
immediate necessity of binding. 

Subscribers will receive fourteen hundred pages of closely printed 
matter of Library in the year. 

The Bulletin of Medical Science will be published monthly, in num- 
bers of thirty-six pacjes. 

It will be supplied to the subscribers to the Select Medical Library 
without any additional cost, on their remil&ng Jive dollars, the subscrip- 
tion price of* the Library for one year. 

Those who wish to lake the Bulletin alone, will have it sent to their 
address for SI per annum. 

Clubs will be furnished wuh six copies of the Bulletin for $5. 

Subscription. — FIVE DOLLARS per annum, in advance; and in no 
single instance, out of the principal cities, will this rule be departed from. 



Any person ordering Books to the value of Ten Dollars from the following list, 
and remitting the amount free of postage, will be entitled to the Bulletin for 
one year, gratis. 

LIST OF WORKS 

SUPPLIED AS 

SELECT MEDICAL LIBRARY 
Extras,-by Mail. 



Subscribers to the Library and Bulletin, and the Medical Faculty in general, 
are respectfully informed that the Publishers will furnish the following Works 
as Extras ; for which purpose they are stitched in thick paper covers, with strong 
elastic backs, similar to the regular numbers; they can be sent by mail at the 
Periodical charge for Postage, which is per sheet, if under 100 miles, l\ cents, 
exceeding that distance, 2£ cents. 

To the name of each work is stated its number of sheets and the selling price; 
so that any gentleman desirous of having one or more Extras will, by remitting 
a note, (or order payable in Philadelphia,) be furnished, by return of mail, 
with whatever he may select, to the amount. 

The Post Office regulations on Periodicals are such that remittances can be 
made with little or no expense to Subscribers or Publishers, — the Postmaster 
enjoying the privilege of franking all such letters. 



N.B. Those works comprised within brackets are bound in one volume, and 
must be ordered as one Extra; 



LEE'S OBSERVATIONS on the PRINCIPAL MEDICAL INSTI-^k 
TUTIONS and PRACTICE of FRANCE, ITALY, and GER- a 
MANY, &c. f with an Appendix on ANIMAL MAGNETISM and ! $ 



HOMCEOPATHY 

JIIN STONE'S SY 
LATHAM'S LECTURES ON CLINICAL MEDICINE. 



rs of MATERIA MEDICA. 3 



$1 35 



A TREATISE ON TETANUS, by Thomas B. Curling. 1 £ [ 

BOUILLAUD ON ACUTE ARTICULAR RHEUMATISM in ^ <( 80 

general. Translated from the French, by Jatnes Kitchen, M.D. j £ (^ 

PRACTICAL OBSERVATIONS on DISEASES of the HEARTA f 
LUNGS, STOMACH, LIVER, &e. By John Marshall, M.D., &c. - I 

\V1 \THERHEAD on DISEASES of the LUNGS ; considered especi- } « < $0 80 
ally in relation to the particular Tissue affected, illustrating the different | £ j 
kinds of Cough, ) ^ 

PRICHARD on INSANITY and other DISEASES affecting the MIND. 
14 sheets. • • • 

DWIDSON and HUDSON'S ESSAYS on the SOURCES and MODE 
OF ACTION OF FEVER. 8 sheets. .... 

MACROBIN'S INTRODUCTION to the STUDY of PRACTICAL MEDI- 
' CINE, being an outline of the Leading Facts and Principles of the Science. 
6 sheets. ' ' 

SIR JAMES CLARK on the SANATIVE INFLUENCE of CLIMATE. 

8 sheeti. • 



1 25 



80 



70 



14 



Catalogue of Works supplied by Mail, 



CHANGES of the BLOOD in DISEASE. Translated from the French of 

M. Gibert, by John H. Dix, M.D., M.M.S.S. 3 sheets. . 50 



HOOKEN on AMAUROSIS and AMAUROTIC AFFECTIONS. 8 sheets. 80 



SIR CHARLES BELL'S INSTITUTES OF SURGERY. Arranged in 
the order of the Lectures delivered in the University of Edinburgh. 19 sheets. $1 50 



EPIDEMICS of the MIDDLE AGES, viz. The Black Death and Dancing 
Mania; translated from the German of Hecker, by Dr. Babington, F.R.S. 
7 sheets. . . . . . . . 60 



The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., from 
November, 1836, to October, 1837. 19 sheets. 



PLUMBE on DISEASES of the SKIN; with splendid coloured Engravings. 
17 sheets. ....... 



TURNBULL'S TREATISE on the MEDICAL PROPERTIES of the \ . 

Natural order RANUNCULACEiE, &c. &c. | ~ 

THE GUMS ; their Structure, Diseases, Sympathies, Sec. By George X^ 

Waite. I " 

An ESSAY on DEW, &c. By \V. C. Wells, F.R.S. J <=> 



COLLINS'S PRACTICAL TREATISE on MIDWIFERY. 11 sheets. 



2 00 



2 25 



85 



1 25 



EVANSON and MAUNSELL on the MANAGEMENT and DISEASES 
of CHILDREN. A new edition in pres3, shortly to be published. 



EDWARDS on the INFLUENCE of PHYSICAL AGENTS on LIFE : 

with observations on ELECTRICITY, «fec. 10 sheets. . 



1 90 



HORNER'S NECROLOGICAL NOTICE OF DR. P. S. PHYSICK.^ . f 
IS MEDICAL SCIENCE FAVOURABLE TO SCEPTICISM ? | f \ 

By Dr. Dale, of Newcastle, Delaware. Ig { 30 

ON DENGUE; its HISTORY, PATHOLOGY, and TREATMENT. | ■ 



By Prof. Dickson of S. C. 



THE FOLLOWING ESSAYS ON PHYSIOLOGY AND HY-^| 
GIENE: — Reid's Experimental Investigation into the Functions 

of the Eighth Pair of Nerves. 
Ehrenberg's Microscopical Observations on the Brain and Nerves; 

with numerous Engravings. 
On the Combination of Motor and Sensitive Nervous Activity ; by 

Prof. Stromeyer, Hanover. 
Vegetable Physiology. 
Experiments on the Brain, Spinal Marrow, and Nerves. By Prof. 

Mayer, of Bonn ; with icood cuts. 
Public Hygiene. 
Progress of the Anatomy and Physiology of the Nervous System, 

during 1836. By Pro. Muller. 
Vitfil St&tistics 
REID on the FUNCTIONS of the EIGHTH PAIR of NERVES, j 



at 
M 



125 




FRECKLETON'S OUTLINES of GENERAL PATHOLOGY. 7 sheets. . 75 



URINARY DISEASES, and their TREATMENT. By R. Willis, M.D., Sec. 

10 sheets. . . . - . , . 1 00 



MILLINGEN'S CURIOSITIES of MEDICAL EXPERIENCE. 15 sheets. 150 



in the Select Medical Library, — extra. 15 

ANDRAL'S MEDICAL CLINIC: Diseases of the Encephalon, Spinal Cord, 
&c. &c. 13 sheets. . . . . . . 1 20 



The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from 
November 1837, to October, 1838. 21 sheets. . . . . $2 00 



LECTURES on the PHYSIOLOGY and DISEASES of the CHEST. By 
Prof. Williams. Willi Engravings. 15 sheets. . . . . 1 75 



LECTURES on BLOOD-LETTING. By Dr. Clutterbuck. 5 sheets. . 65 



MEDICAL and TOPOGRAPHICAL OBSERVATIONS upon the MEDI- 
TERRANEAN, and upon PORTUGAL, SPAIN, and other countries. By 
G. R. B. Homer, Surgeon U. S. N., &c. Illustrated with Engravings. 
9 sheets. . . . . . . . 1 00 



MAGENDIE'S LECTURES on the BLOOD: its Changes during Disease, 
&c. 12 sheets. . . . . . . . 1 25 



The ECLECTIC JOURNAL of MEDICINE, by John Bell, M.D., &c, from 

November, 1838, to October, 1839. 20 sheets. . . . 2 00 



HOLLAND'S MEDICAL NOTES and REFLECTIONS. 16 sheets. . 160 



ARMY METEOROLOGICAL REGISTER for the YEARS 1826,^) 
1827, 1828, 1829, and 1830. » 

HINTS on the MEDICAL EXAMINATION of RECRUITS for the ! g < 
ARMY; and on the Discharge of Soldiers from the Service on { •§ » 
S d aeon's Certificate : Adapted to the Service of the United States. By | 
TfeonMJ Heuderson, M.D., Assistant Surgeon U. S. Army, &c, &c.J 



65 



MACARTNEY on INFLAMMATION. 5 sheets. . . .0 50 



75 



75 



1 00 



HI" It NT. on HABITUAL CONSTIPATION— its Causes and Consequences. 

7 -heets. • • • • 

A PRACTICAL TREATISE ou VENEREAL DISORDERS, &c^ ^ C 

j;;.!:;^ of urine, J 

A CAU8EDoy STRICTURESof the URETHRA, and on the Diseases * 
Of the Prostate. Translated from the French by James P. Jervey, M.D.J L 

"* } % ( 

r<()ITROL on MENTAL DISEASES. 1$) 

AN ESSAY ON HYSTERIA. With numerous Illustrative and Curious ^ I 

Cases. By Thomas Laycock. J 2 I 

SURGICAL OPERATIO NS. ■> *■ 

The ECLECTIC JOURNAL of MEDICINE^^ Bell, M.D., &c, from 

November, 1839, to Octo ber, 1840. 20 sheets. . 

GOOCH'S PRACTICAL'COMPENDIUM of MIDWIFERY. 14 sheets.. 100 

r n iVF55 ,o riTNICAL LECTURES. With Notes and Fifteen additional 
G ^"byTw C tohlrf^ on Clinical Median, to the Urn- g ^ 

versity of Pennsylvania, etc. 23 sheets. 



16 



Catalogue of Works supplied by Mail — extra. 



ELEMENTS OF SURGERY, in Three Parts. By Robert Listok, 
Fellow of the Royal College of Surgeons in London and Edinburgh, 
&c. Third American, from the Second London Edition, with upwards 
of one hundred and sixty illustrative engravings. Edited by Samuel D. 
Gross, M.D., Professor of Surgery, Louisville Medical Institute. Author 
of Elements of Pathological Anatomy, etc.. etc. 1 vol. 8to. 




3 00 



THE HISTORY, PATHOLOGY, AND TREATMENTS PUERO f 
PERAL FEVER AND CRURAL PHLEBITIS. By Drs. Gordon, | « | 
Hey, Armstrong, and Lee; with an INTRODUCTORY ESSAY L §J 41 ^ 
by Charles D. Meigs, M.D., Professor of Obstetrics and the Diseases fis', * X W 
of Women and Children in the Jefferson Medical College, Philadel- ^ | 
phia. 1 vol. 8\o. . . . . . • J " L 



DERANGEMENTS, PRIMARY AND REFLEX, OF THE ORGANS 
OF DIGESTION. By Robert Dick, M.D., author of * A Treatise on Diet 
and Regimen." 1 vol. 8vo. 10 sheets. . . . .1 



DISEASES OF THE LIVER AND BILIARY PASSAGES, by^i .- 
William Thomson, one of the Physicians of the Royal Infirmary of I "S 
Edinburgh; and CLINICAL ILLUSTRATIONS OF THE LIVER \Js 
AND SPLEEN, by William Twining ; Surgeon of General Hospital j ^ 
of Calcutta, &c, &c, 1 vol. 8vo. . . . .J 1 " 1 



40 



1 60 



A TREATISE ON THE DISEASES OF CHILDREN, VVITH^i . f 
DIRECTIONS FOR THE MANAGEMENT OF INFANTS; by ~ | 

the late Michael Underwood, M.D. From the ninth English edition, }2 t 
with notes by S. Merriman, M.D., and Marshall Hall, M.D., I " 
F.R.S., &c, with notes by John Bell, M.D., &c. . • J " I 



LECTURES ON THE FUNCTIONS AND DISEASES OF THE") 
WOMB; by Charles Waller, M.D., Bartholomew's Hospital. » 

ON DISEASES OF THE UTERUS AND ITS APPENDAGES; K g 
by M. Lisfranc, La Pitie Hospital. (■% 

ON DISEASES OF THE PUERPERAL STATE; by J. T. Ingleby | © 
Edinburgh, 1 vol. 8\o. J ^ L 



APHORISMS ON THE TREATMENT 
THE INSANE ; by J. G. Millingen, M.D. 



AND MANAGEMENT 

1 vol. 8vo. 4 sheets. 



OF 



A PRACTICAL DICTIONARY OF MATERIA MEDICA, Inclod-"] 
ing the Composition, Preparation and Uses of Medicine; and a large I i 
number of Extemporaneous Formulae together with important Toxi- I g 
cological Observations; on the Basis of Brande's Dictionary of Materia [ -^ 
Medica and Practical Pharmacy: by John Bell, M.D 
Materia Medica and Therapeutics, &c.&c. 1 vol. 8vo. 



Lecturer on | ~ 



'} 



L 

OUTLINES OF PATHOLOGICAL SEMEIOLOGY. Translated from 
the German of Professor Schill. With copious notes by D. Sfillman, 
M.D.,A.M., &c, &c. lvol.8vo. 9 sheets. . 






1 75 



J< 1 10 



38 



1 00 



ARET.EUS ON THE CAUSES AND SIGNS OF ACUTE AND 
CHRONIC DISEASE. From the Greek, by T. F. Reynolds, M.B., F.L.S., 
&c, &c. 1 vol. 8vo. 4 sheets. ..... 

LECTURES ON THE MORBID ANATOMY, NATURE. AND") . f 
TREATMENT OF ACUTE AND CHRONIC DISEASES. By | 2 

the late John Armstrong, M.D., Author of " Practical Illustrations of S = < 
Typhous and Scarlet Fever," &c. Edited by Joseph Rix, Member of j 1 | 
the Royal College of Surgeons. 1 vol. Svo. J N I 

BLUNDELL'S LECTURES ON THE PRINCIPLES AND PRACTICE 
OF MIDWIFERY. Edited by Charles Severn, lvol. 6 vo. 19 sheets. . 150 



50 



2 75 









</ - 






^ 


















'> 









^ % 


















>\ 







** 



,o- 









& 









V 















& 



,0o 



i> «. s * * / , V. 












V </> 






L 1 8 4 






b>% % 



> A ' s 






^ ,<Y> 



o\ 



^ 



^V - X ' B * 









J 



£ ^ 






vV AP >* 





^ 



































*>• 






x ^ 













V- 



W\^** 



^ 






^ * 



V* <^ 



- \* 



3* ^ ^ 



/, c- 











$\ 


& 






o 






1 ft '/' 






1 B 4 


,-0' 


















